Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was adequately supervised to prevent her exiting the facility without staff knowledge for 1 (R1) of 3 residents reviewed for accidents and supervision in the sample of 3. This failure resulted in R1, who has a diagnosis of dementia and was already on 15-minute visual checks for previous exit seeking behavior, exiting the facility at an unknown time without staff knowledge or supervision, walking approximately 1.3 miles away from the facility and was found by two unknown teenage female citizens who took R1 to the local emergency room. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 5/15/2025 at approximately 7:45pm when R1 exited the facility and was found by two teenage girls approximately 1.3 miles from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 5/21/2025 at 4:30pm. The surveyor confirmed by observation, record review and interview that the immediacy was removed on 5/22/2025. Findings include: R1's Facility admission Record documented R1 was admitted to this facility on 4/13/2025 with diagnoses of Parkinsonism and unspecified dementia among others. R1's MDS (minimum data set) dated 4/19/2025 documented R1 with a BIMS (brief interview for mental status) score of 6 out of 15 total which indicates R1 has severe cognitive impairment. R1's admission elopement evaluation (dated 4/13/2025) documented R1 with an elopement risk score of 0.0 which indicated no elopement risk. A progress note dated 5/13/2025 in R1's electronic health record documented R1 had attempted to leave the facility multiple times and was placed on 15-minute visual checks. On 5/21/2025, V18 (Licensed Practical Nurse/LPN) said she was the nurse caring for R1 on 5/13/2025 when R1 attempted to leave the facility without staff. V18 said R1 may use a wheelchair to get about the facility but R1 can walk well. V18 said R1 was attempting to leave the facility via the front door and was spotted by V17 (LPN) and brought back inside the facility and placed on 15-minute visual checks. V18 said at this facility the nurses are responsible for performing and documenting the 15-minute visual checks. On 5/13/2025, R1 was re-evaluated for elopement risk and scored a 3 which indicates R1 is an elopement risk. R1's care plan was updated 5/13/2025, to include 15-minute visual checks for attempted elopements from the facility. A form titled Long Term Care Facility Serious Injury Incident and Communicable Disease Report dated 5/16/2025 documented on 5/15/2025 at 8:15pm, R1 had exited the facility without staff knowledge even though R1 was on 15-minute visual checks. The report documented R1 became upset with another resident and decided to go home, left the facility, and was assisted by two juveniles and taken to the local hospital. On 5/16/2025 at 12:05pm, V13 (Hospital Registered Nurse) said on 5/15/2025 around 8:00pm, two unknown teenage females brought R1 into the local emergency room for help. V13 said the teenagers found R1 lying in the ditch next to the cemetery. V13 said the teenagers did not know R1 and she did not get the teenagers names. V13 said R1 was not injured and thus was not actually registered as a patient that evening. V13 said the local police were called to assist in identifying where R1 belonged but a policeman did not come to the hospital and a report was not completed as far as she knew. V13 said R1 eventually told them her name and birthday and they were able to look R1 up in the hospital's computer system. V13 said she was able to find R1 in the computer system and located a working phone number for R1's son (V15/Family). V13 said she called V15 around 9:15pm and learned R1 lived at the local nursing home. V13 said she called the nursing home at 9:20pm and requested them to come pick up R1. V13 said when R1 was brought into the hospital that evening, R1 was wearing a turtleneck sweater, jeans, and a coat, but the weather was very warm that night. On 5/21/2025 at 10:15am, V15 (Family) said on 5/15/2025 at 9:15pm, he received a call from V13 (Hospital Registered Nurse) to report R1 had been brought into the local hospital by two teenage girls after being found in a ditch near the local cemetery about a mile away from the nursing home. V15 said R1 was not hurt. V15 said R1's previous home is next to the cemetery where she was found. V15 said he told V13 that R1 lived at the nursing home. V15 said V13 called the nursing home, and the nursing home staff came to the hospital and picked up R1. On 5/21/2025 at 10:00am, V14 (Licensed Practical Nurse/LPN) said she was the nurse providing care for R1 during the day on 5/15/2025. V14 said she did not know R1 had previously attempted to leave the facility without staff on 5/13/2025 and was placed on 15-minute visual checks. V14 said this information was not passed on to her in shift report and she had been off for a few days. V14 said since she did not know R1 was on 15-minute visual checks, she did not perform the checks and did not pass this information on to the next nurse on duty which was V3 (Registered Nurse/RN). On 5/21/2025 at 10:30am, V3 said she, V6 (Certified Nursing Assistant/CNA) and V8 (CNA) were the staff providing care for R1 on the evening of 5/15/2025. V3 said she did not know R1 was on 15-minute visual checks as this information was not passed on to her in shift report. V3 said since she did not know R1 was on 15-minute visual checks, she was not performing the checks on the evening of 5/15/2025 when R1 left the facility without staff knowledge. V3 said she last remembered seeing R1 in her room around 7:30pm. V3 said she did not know R1 was missing from the facility until the hospital called the nursing home about 9:15pm to report R1 was at the hospital, needed picked up and was not injured. V3 said she sent V6 over to the hospital to pick up R1 and return her to the nursing home. V3 said after R1 returned to the facility she discovered R1 was already supposed to be on 15-minute visual checks and completed the 15-minute visual check sheet at that time. On 5/21/2025 at 2:15pm, V6 said she worked on R1's unit the evening of 5/15/2025. V6 said she had not worked for a few days and did not know R1 had attempted to leave the facility without staff on 5/13/2025 and was placed on 15-minute visual checks. V6 said this information was not passed on to her in shift report. V6 said the nurses are responsible for performing and documenting the 15-minute visual checks so she did not know anything about it. V6 said on 5/15/2025 the last time she remembered seeing R1 at the facility was around 7:30pm and R1 was in her room. V6 said she did not know R1 was missing from the facility until V3 (RN) received a call from the hospital around 9:15pm. V6 said she was sent to the hospital to get R1 and bring her back to the facility. On 5/21/2025 at 2:45pm, V8 said she worked R1's unit the evening of 5/15/2025. V8 said she had been off for a few days and did not know R1 had attempted to leave the facility without staff on 5/13/2025 and was placed on 15-minute visual checks. V8 said the nurses perform the 15-minute checks so she had no knowledge of R1 being on 15-minute visual checks. V8 said on 5/15/2025, she returned from her lunch break around 7:45pm and she seen R1 in her room. V8 said she did not know R1 was missing from the facility until 9:15pm when V3 (RN) received a phone call from the hospital reporting R1 was there without staff. On 5/21/2025 at 2:20pm, V5 (CNA) said she was working the evening of 5/15/2025 but was not on R1's unit. V5 said she did not know R1 was on 15-minute visual checks for elopement attempts. V5 said every evening between 6:00pm and 8:30pm the facility's door alarm is constantly alarming due to family members coming in and out of the facility. V5 said on 5/15/2025 around 7:30pm, she noticed the facility's front door alarm sounding and no one was around. V5 said she looked outside of the front door and did not see anyone. V5 said she reset the alarm and returned to work without telling any other staff about the alarming door. V5 said she feels this could be when R1 left the facility. V5 said she found out later that night around 9:30pm that R1 was missing from the facility after the hospital called to report R1 was at the hospital without staff. On 5/22/2025 at 1:45pm, R1 was observed walking with a wheeled walker with V16 (Physical Therapy Assistant) around the facility. R1 easily walked with a steady gait and lifted up and carried the wheeled walker when going over thresholds without losing her balance. V16 said R1 can walk very well and doesn't really need to use a wheelchair. V16 said on good days, R1 walks me instead of me walking R1. The facility's 24-Hour Report sheet for R1's unit dated 5/13/2025 documented R1 was started on 15-minute visual checks and the dressing to R1's left thumb was changed. The facility's 24-Hour Report sheet for R1's unit dated 5/14/2025 documented R1's dressing to the left thumb was changed and did not include any information about R1 being on 15-minute visual checks. The facility's 24-Hour Report sheet for R1's unit dated 5/15/2025 documented R1 had a new medication order and did not include any information about R1 being on 15-minute visual checks. R1's 15-minute visual check sheets dated 5/15/2025 documented V3 observed R1 in her room at 8:00pm. At 8:15pm, a question mark was documented for R1's location by V3. At 8:30pm, hosp (hospital) was documented for R1's location by V3. At 8:45pm, hosp was documented for R1's location by V3. At 9:00pm, hosp was documented for R1's location by V3. At 9:15pm, hosp was documented for R1's location by V3. At 9:30pm, R1 was documented in her room by V3. An undated facility policy titled Facility Door Alarms under the section titled Procedure For Response To Sounding Door Alarm documented Nurse or designee will identify the location of the door alarm triggered. The nurse or designee will notify the appropriate nursing station. The nurse or designee will go to identify the exit and verify reason for the triggered alarm. If the reason for the sounding alarm is not identified, the location of all residents known as a Wander/Elopement Risk will be verified. At no time will the sounding door alarm be canceled before verification is confirmed. An undated facility policy titled Wandering and Elopements documented the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident and if on 15-minute visual (checks) put on 24-hour report (sheet) until d/c'd (discontinued). The Immediate Jeopardy that began on 5/15/2025 was removed on 5/22/2025 when the facility took the following actions to remove the immediacy and correct the noncompliance. On 5/15/2025 at 9:30pm, R1 returned to the facility and was placed on 1:1 monitoring which continued until 5/16/2025 at 7:45am when an exiting alarm device was placed on R1's wrist. R1 continues on 15-minute visual checks. All staff, including department heads, have been educated to ensure that they are aware of policy related to resident elopement, wandering and 15-minute visual checks. Education was provided by V11 (Assistant Director of Nursing) and was completed on 5/15/2025 and 5/22/2025, with education on-going. On 5/22/2025 a Quality Assurance and Performance Improvement meeting was held and the plan of correction and implementation was documented as follows: 1. The facility reviewed the policy and procedures for door alarms, 15-minute visual checks. Missing residents, and elopements. (Staff) to make sure anyone on 15-minute visual checks is placed on the 24-hour report sheets daily. All reviewed with staff. 2. All residents at risk for elopement were reassessed. 3. All residents who are elopement risk will be reassessed as necessary. 4. Monitor door alarms for staff properly following protocol. 5. V1 (Administrator) in-serviced staff, Assistant Director of Nursing, and all department managers. 6. V1 ensured residents, who are identified as high elopement risk, have updated and correct information about them in the facility's elopement book at both nurses' stations. 7. Monitor staff for compliance with door alarm procedure. 8. Review nursing for completing assessments on high elopement risk residents. 9. Director of Nursing or Designee to monitor all for compliance weekly for two weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect a resident's right to be free from neglect when they failed identify a change in condition as emergent and to ensure a system was in place to obtain timely emergency transport for 1 of 3 (R1) residents reviewed for neglect in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. This failure has the potential to affect all 37 residents residing at the facility. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 10/04/23 when the facility failed to ensure R1 received timely medical care when they failed to recognize an emergent situation and call 911 after the ambulance provider they called was delayed. This failure resulted in R1 remaining at the facility from 6:39 AM until the ambulance arrived at 7:35 AM with worsening symptoms. R1 was subsequently transferred to the local hospital, went into cardiac arrest during transfer, and expired in the hospital emergency room on [DATE]. R1's cause of death is documented as a massive gastrointestinal (GI) bleed. V1 (Administrator) was notified of the Immediate Jeopardy on 10/17/23 at 9:14 AM. The surveyor confirmed by record review and interview, that the Immediate Jeopardy was removed on 10/17/23 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training. Findings Include: R1's admission Record with a print date of 10/12/23 documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, malignant neoplasm of pancreas, atrial fibrillation, restless leg syndrome, neuromuscular dysfunction of bladder, major depressive disorder, cognitive communication deficit, and weakness. R1's MDS (Minimum Data Set) dated 7/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 was cognitively intact. R1's Order Summary Report with active orders as of 9/30/23 documents a physician order that R1 was a full code and a physician order for Xarelto 20 milligrams (mg) one every afternoon. R1's Care Plan documents a Focus area with a created date of 6/30/23 documents, Usage of black box medications: .Xarelto . The interventions documented for this Focus area include, Monitor and assess for side effects of medications that contain black box warning PRN (as needed). R1's Care Plan documents a Focus area with a created date of 6/27/23 of, (R1) wishes to return home with (name of home health agencies). The intervention documented for this Focus area is, Evaluate and discuss with the (R1) and (V19) the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits, and needs for maximum independence. R1's Power of Attorney for Health Care dated 6/27/23 documents V19 (family member/spouse) was R1's agent to make decisions for her when she was not able to make them for herself. The form documents a check mark next to the following statement, Staying alive is more important to me, no matter how sick I am, how much I am suffering, the cost of the procedures, or how unlikely my chances for recovery are. I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical standards. R1's Social Services Assessment and Note dated 6/27/23 documents under Social Service Note, (R1) was admitted to (name of facility) for a short-term therapy stay following a long hospitalization. POLST (Physician Orders for Life Sustaining Treatment) FULL CODE per choice. HCPOA (Health Care Power of Attorney) husband (V19) 6/26/23 . R1's Progress Notes document the following: 10/03/23 2:20 PM, resident (R1) is alert, verbal, oriented x 2, sleeps well at night. 10/04/23 6:50 AM, AM ADL's (activities of daily living) to go get chemo (chemotherapy) port placement this am. Res (R1) has been NPO (nothing by mouth). CNA (Certified Nursing Assistant) called this writer (V14) to room. (R1) having difficulty with speech et (and) slow to respond. CNAs stated at oncome of shift at 0600 (6:00 AM) was talking fine. Pupils sluggish to response, dilated. Bilat (bilateral) upper ext. (extremity) edema. Unable to get O2 sat (saturation), pale but no discoloration. Blanches pink nail beds, flaccid strength per her norm, total assist, blankets applied to increase temp (temperature) skin cool, 95.7 122/88, 84, 20 room air. Called (V24/NP-Nurse Practitioner) send to ER (emergency room) for evaluation r/t (related to) condition change. (Name of ambulance service) called at 0655 (6:55 AM) called husband and made aware of. This writer staying by room to monitor. This progress note was signed by V14 (LPN/Licensed Practical Nurse). 10/04/23 7:35 AM, (ambulance service) here. 0745 (7:45 AM) Exit with (R1) per transfer of 4 to stretcher. 10/04/23 10:15 AM, husband here et made aware of wife expiring. Hugged this nurse et stated thank you for taking good care of her. Belongings taken at this time. Administrators present with facilities (sic) condolences. Called (V24) et made aware of (R1) expiring per notification from husband. R1's Ambulance Patient Care Report dated 10/04/2023 documents under Response Information the Nature of Call as Medical Emergency and documents, Caller (Uncooperative) No EMS (Emergency Medical Service) Vehicles (Units) Available. Under Times the report documents, Injury: 0659 (AM) .Recvd (received) 06:59 (AM) .Dispatch: 07:35 (AM) . The Patient Care Report documents Altered Consciousness-Unresponsive as the chief complaint. Under Narrative the report documents, Responded emergent for a direct call to (name of facility) report of a female with flaccid, decline in responsiveness, and uneven pupils. Per dispatch nursing home refused to call 911 and wanted to wait for (name of ambulance service) ambulance knowing it (sic) we don't have any units available and will be a while. Delay to scene due to no units available. AOS (arrived on scene) to find pt (patient/R1) laying in nursing home bed. Per nursing home staff, staff noticed a change in (R1's) condition around 0600 (6:00 AM) this morning when they started their shift. Further, nurse states (R1's) temperature is 95.4 and they are attempting to warm her. (R1) is unresponsive, pale, cool, and clammy. (R1) moved to cot, secured, and loaded into ambulance. (R1) has a PICC (peripherally inserted central catheter) line to her left upper arm. (R1) placed on cardiac monitor showing sinus bradycardia, (R1) went into cardiac arrest. CPR (Cardiopulmonary Resuscitation) immediately started by (names of paramedics and emergency medical technician) contacted (name of local hospital) ED (Emergency Department) to given (sic) (R1) update upon arrival. Pads placed on (R1) showing asystole. ER (Emergency Room) staff met this unit outside and assisted in taking (R1) into emergency room .(R1) care left with ER nursing staff R1's local hospital emergency department record dated 10/04/23 documents under History, Chief Complaint Patient (R1) presents with Cardiac Arrest. Pt (R1) per EMS (emergency medical services) has been told by NH (nursing home) staff unresponsive since 0600 (6:00 AM) . they were called just pta (prior to arrival) and found (R1) unresponsive hr (heart rate) 30's in route just across street full arrest they started CPR (cardiopulmonary resuscitation) large amt (amount) of black vomit on arrival asystole on arrival accu (sic) done by us 84 on arrival, CPR continued going thru epi (epinephrine) x (times) 3, attempted intubations very large vomit in airway clogging up many yankars with blood clots difficult to get clear site, unable to pass 7 tube ? (question) mass beyond tried 6.5 still unable getting video stylet unable to see, anesthesia called but placed lma (laryngeal mask airway) and b/l (bilateral) bs (breath sounds) after still asystole and (R1) pupils fixed dilated on arrival pale waxy color entire time and US (ultrasound) cardiac no activity no pulse called TOD (time of death) at 0808 (8:08 AM). Under Physical Exam R1's hospital record documents, BP (blood pressure) 56/38, SpO2 85% .fixed and dilated pupils .pulse with CPR then nothing .bagging after lma b/l bs. R1's hospital record documents Cardiac Arrest under ED (Emergency Department) Course, Clinical Impressions. R1's Certificate of Death Worksheet documents R1 expired on 10/04/23 and Cause of Death is documented as Massive Gastrointestinal Bleed. On 10/11/23 at 4:17 PM, V12 (CNA) stated she provided care to R1 on 10/02, 10/3, and 10/04/23. V12 stated on 10/2 and 10/3/23, R1 refused to eat and didn't want to get out of bed on those days. V12 stated R1 wasn't talking as loud, she was kind of quiet and mumbly (sic). V12 stated she came to work on 10/04/23 and it was reported to her by night shift, R1 had complained of not feeling well through the night. V12 stated she went straight to R1's room after she got report at 6:00 AM. V12 stated she told V14 (LPN/Licensed Practical Nurse) to assess R1. V12 stated V14 first said she was going to send R1 out to the hospital for evaluation and then changed her mind and had them get R1 up to go to the appointment she had. V12 stated they got R1 up and took her to the nurse's station. V12 stated they took R1's temperature and it was around 95.0. V12 stated, V14 told them to put R1 back to bed they were calling the ambulance. V12 stated V14 told them it was going to be a little bit before the ambulance could get there because they had someone going out on a helicopter. V12 stated at that point R1 was cold and was still speaking and told them she was hurting all over. V12 stated then R1 was kind of hollering and yelling. V12 stated, V25 (PTA/Physical Therapy Assistant) went in to check on R1 and R1 told V25 she was hurting all over. V12 stated she checked on R1 around 7:00 AM and at that time R1 was not able to verbally communicate with words. V12 stated the ambulance got to the facility around 7:30 AM. V12 stated R1 was alert but they couldn't get her to speak at that point. V12 stated the ambulance crew asked V14 as soon they got in the room why she refused to call 911. V12 said V14 told the ambulance crew as far as she knew there were no ambulances. On 10/16/23 at 11:28 AM, V25 (PTA) stated she was walking another resident down the hall when she heard R1 screaming and yelling, help me, help me. V25 stated she finished walking the resident down the hall and went back to check on R1. V25 stated she asked R1 if she was ok and R1 didn't respond. V25 stated R1 was looking up at the ceiling so she asked R1 if she was hurting. V25 stated R1 said yes and when she asked her where she was hurting R1 screamed, everywhere. When asked if that was normal behavior for R1, V25 stated, no. V25 stated she had never heard R1 scream out like that. V25 stated R1 was definitely not a screamer. V25 stated R1 was hollering and V25 mimicked a continuous holler. V25 stated at first there were no words and then R1 yelled the word, everywhere. V25 stated she thought this was around 6:30 AM then stated it was between 7:15 and 7:30 AM. V25 stated she reported it to the V14 (LPN). V27 stated an unknown CNA told her they had already contacted the ambulance and they were just waiting on the ambulance to get free to come get R1. On 10/11/23 at 3:27 PM, V9 (CNA) stated she provided care to R1 in the days leading up to 10/04/23 and was working when R1 was sent to the hospital. V9 stated R1 had progressively gotten worse in the three days prior to 10/04/23. V9 stated she got to work on the morning of 10/04/23 around 5:50 AM. V9 stated R1 had an appointment scheduled for that morning so she and another CNA (V12) went to R1's room around 6:10 AM. V9 stated R1 was really out of it. V9 stated they reported it to the nurse (V14). V9 stated V14 told them to get R1 up so she could go to her appointment, so they did. V9 stated they took R1 to the nurse's station and R1 was very cold. V9 stated V14 told them to put R1 back to bed and they were sending R1 to the hospital. When asked how long it took the ambulance to arrive, V9 stated she knew it was a whole big ordeal. V9 stated she knew they called the ambulance, and they said it was going to be awhile before they could get to the facility. V9 was not able to say when the ambulance arrived. V9 stated she remembered R1 yelling and just trying to talk while V9 was trying to get other residents up. V9 stated she kept going in R1's room to check on her. V9 stated R1 was trying to talk but couldn't get her words out, but she was yelling and mumbling. V9 stated R1 worsened because she was able to say her name when she first saw her around 6:10 AM. When asked if a nurse was with R1 during this time frame, V9 stated, not the whole time but she was in the room multiple times. On 10/12/23 at 9:38 AM, V14 (LPN) stated she provided care to R1 on 10/04/23. V14 stated she started her shift at 6:00 AM and went to R1's room around 6:05 AM. V14 stated right after that V9 and V12 (CNAs) reported to her R1 was acting different. V14 stated she assessed R1 including checking her vital signs and R1's blood pressure was 122/88. V14 stated R1 was sluggish to respond but was vocal at that time. V14 stated R1's temperature was 95.7 Fahrenheit and hypothermic measures were implemented such as extra blankets. V14 stated R1 was full of fluid but blanched pink when she blanched her. V14 stated she called the ambulance service direct around 6:15 AM and told them R1 was sluggish to respond and slurring her words, a change from 10 minutes prior. V14 stated the ambulance service told her they would send someone out. V14 stated she then went to R1's room and stayed with her. V14 then stated she passed medications to other residents on the same hallway. When asked if that meant she wasn't with R1 the whole time, V14 stated, No, not the whole time. V14 stated R1 looked as though she was resting. When asked when the ambulance service arrived, V14 stated, V20 (RN/Registered Nurse) hollered down and told her there were two helicopters and all the ambulance crews were tied up, so that delayed them from arriving at the facility. V14 stated she would guess they arrived at the facility around 7:15 or 7:20 AM. V14 stated she didn't call 911. V14 stated she didn't realize she had an emergent situation. V14 stated R1 had a condition change and she wanted her out of the facility as fast as she could go but didn't think she was going to pass away. V14 stated the normal procedure for sending a resident to the hospital is to call the ambulance service direct. V14 stated she thought calling them would be her fastest response. On 10/11/23 at 4:31 PM, V13 (EMT/Emergency Medical Technician, Basic) stated she transported R1 from the facility to the local hospital on [DATE]. V13 stated it was unusual because R1's call came while she was on another call. V13 stated she was on the helipad and the patient she was working with had a soft blood pressure so the helicopter couldn't leave. V13 stated when that happens the ground crew can't leave the helipad. V13 stated she got the call around 6:39 AM from the night shift dispatcher (V27) that there was a resident (R1) at the facility with uneven pupils, flaccid, unresponsive, and sitting at the nurse's station. V13 stated she responded to dispatch to call the facility and tell them to call another service because with those symptoms they needed immediate transport, and the other crew was in another city on a different transport. V13 stated she returned to the helipad, and she got another call from dispatch at around 7:00 AM. V13 stated dispatch told her the resident (R1) was still waiting for transport. V13 stated she explained to dispatch R1 couldn't wait. V13 stated they finished at the helipad around 7:35 AM and when they called in that the call, they were on was complete, they were told the resident (R1) was still waiting for transport at the facility. V13 stated they went in route to the facility and arrived within less than two minutes. V13 stated the nurse (V14) told them R1 was in bed, and they were trying to warm her since her temperature was 95.4. V13 stated they asked her why she didn't call 911 and V14 told them she was busy on the hall. V13 stated when they got to R1's room she was in bed laying under a blanket. V13 stated R1 was diaphoretic, cold to touch gray/blue around her lips and outside her mouth, both pupils were dilated, and the left pupil measured a 6 while the right pupil was an 8. V13 stated facility staff helped transfer R1 to the cot and they started oxygen immediately. V13 couldn't remember if oxygen had been applied by the facility staff prior to their arrival. V13 stated once in the ambulance her partner attempted to start an IV (intravenous access) and they were unable to get a blood pressure. V13 stated then R1 went loose and lost her pulse. V13 stated they started CPR and R1 was spewing coffee ground emesis with compressions. V13 stated they were in route to the hospital which is less than two minutes away and they turned her care over to the ER staff when they arrived. On 10/13/23 at 4:04 PM, V27 (Dispatcher, Ambulance Service) stated she works at the ambulance service as a dispatcher on the 11 PM to 7 AM shift. V27 stated she received a call from the facility around 6:39 AM on 10/04/23 and the nurse (V14) gave her the information on R1. V27 stated she told V14 there was no crew available because they had a crew going to a regional hospital and one on the helipad. V27 stated V14 said she guessed she would wait for them. V27 stated she called the crew to get an established time frame and they said it would be 30-40 minutes. V27 stated she called the facility back around 7:00 AM to make them aware of the time frame. V27 stated she didn't get the name of the nurse who answered the phone, but she told them the time frame and they said they would let the nurse know. V27 stated it took the crew approximately 30 minutes after that to get to the facility. On 10/11/23 at 12:02 PM, V5 (Ambulance Dispatcher) stated he came on duty on 10/04/23 at 7:00 AM. V5 stated the original call came from the facility at 6:39 AM. V5 stated they had one ambulance crew out of town doing a run and a second crew working on the helipad with a stroke victim. V5 stated the night shift dispatcher (V27) called the facility back at 7:02 AM and told them it was still going to be thirty minutes before they could arrive to the facility to transport R1 to the local hospital. V5 stated the facility said they would wait. V5 stated the crew arrived at the facility at 7:35 AM. On 10/18/23 at 11:22 AM, when asked why the time on R1's ambulance report is documented as 6:59 AM when all the interviews say the first call came from the facility at 6:39 AM, V5 (ambulance dispatcher) stated the original call came in at 6:39 AM but they didn't create the call in the system because they didn't know if they would be taking the call. V5 stated they didn't create the call in the system until they talked to the crew and called the facility back. V5 stated he took a picture of the time the calls came in and the original call's picture shows it was 6:3*, with the last number not visible. V5 stated the time stamp on the call logs shows the ambulance service called the facility back at 7:02 AM. On 10/12/23 at 11:19 AM, V17 (LPN) stated she was working the day R1 was sent to the hospital. V17 stated they were getting ready to start morning medication pass and the CNAs brought R1 up for breakfast. V17 stated V14 (LPN) said she was going to send R1 out to the hospital. V17 stated they took R1 to her room and V17 started passing medications. V17 stated the ambulance service called back and said they were 20-30 minutes out. V17 stated she remembered calling that information down to V14. V17 stated she talked to R1 on her way out the door and told her goodbye. When asked if R1 responded to her, V17 stated she couldn't remember. On 10/12/23 at 1:37 PM, V20 (RN) stated she works night shift and on the morning of 10/04/23 she gave report to the oncoming nurse (V14) at approximately 6:00 AM. V20 stated V14 brought R1 to the nurse's desk and V14 said something was wrong with R1. V20 stated it was a change in condition from when she had seen R1 around 2:30 AM, when R1 was talking and asking to be repositioned. V20 stated V14 was having trouble getting R1's vital signs so she helped her and V14 called the ambulance. V20 stated she was working on paperwork when the ambulance called back, and she answered the phone. V20 stated they told her they were going to be about 30 minutes. V20 stated she told the other nurse (V17) and V17 told V14. V20 stated she finished her work and left, and the ambulance had not arrived at the facility when she left. When asked if it was typical for the ambulance to take an extra 30 minutes, V20 stated, At times they do, When asked what they normally do in those situations V20 stated she would either call another ambulance service or call 911. On 10/12/23 at 2:33 PM, V23 (CNA) stated she worked the night before R1 was sent to the hospital. V23 stated R1 was talking to her when she left the facility the morning of 10/04/23 at 6:00 AM. V23 stated R1 was very restless through the night shift and said she just didn't feel good and couldn't get comfortable. V23 stated R1's hands were very swollen and R1 couldn't use them. On 10/12/23 at 3:24 PM, V26 (CNA) stated she worked night shift beginning on 10/03/23 and leaving on the morning of 10/04/23. V26 stated R1 was very uncomfortable, R1's hands were swollen, and R1 seemed really nervous like she was scared or something. V26 stated R1 complained of a stomachache and so they gave her some tums and it helped. When asked how R1 was when she left the facility at 6:00 AM, V26 stated R1 had been up all night and was sleeping so she let her sleep. On 10/12/23 at 1:14 PM, V19 (family member) stated he saw R1 on 9/30/23 and 10/01/23. V19 stated R1 couldn't swallow and seemed kind of groggy. V19 stated the facility called him on 10/04/23 and told him they were transferring R1 to the hospital and then the hospital called him a lot later with an update. When asked what time the facility called him V19 stated he told V22 (family member). On 10/10/23 at 1:22 PM, V22 (family member) stated the facility called V19 on 10/04/23 at 6:30 AM and told V19, R1 was not acting right. V22 stated around 7:45 AM, R1 arrived at the hospital in cardiac arrest. On 10/11/23 at 3:01 PM, V6 (LPN) stated the typical time to transfer a resident to the hospital is thirty minutes or so if the ambulance is backed up. V6 stated it has taken longer. V6 stated it has taken up to an hour. When asked if there was another option for an ambulance service V6 stated the name of another ambulance service provider and stated but sometimes they don't come this way. V6 then stated, Honestly, if it came down to it, I would push them to the hospital. It is right next door. When asked who she calls when they need an ambulance V6 stated, if they are unresponsive, I call 911. When asked if she was providing care to R1 when she was transferred to the hospital on [DATE], V6 stated she was not. V6 stated, She (R1) wasn't one to give up. I was kind of shocked when I found out she had passed away. On 10/11/23 at 3:39 PM, V10 (LPN) stated she didn't provide care for R1. When asked what the process was to send a resident to the hospital V10 stated, they assess the resident, call the physician, get the orders, call the power of attorney, ambulance, and hospital. When asked how long this process takes V10 stated 15-20 minutes or less if there are two nurses working on it. V10 stated it usually takes the ambulance 5-10 minutes to arrive. On 10/12/23 at 10:07 AM, V15 (RN) stated the normal procedure for sending a resident to the hospital would be to assess the resident, call the doctor, if emergent she would get another nurse to get the paperwork started and call the ambulance. V15 stated if not emergent she would call the doctor, get the paperwork printed and get them sent out. V15 stated unless there is a delay with the ambulance it is a pretty speedy process. When asked what would cause a delay V15 stated the ambulance service sometimes says they don't have any crews available. V15 stated they have more than one ambulance service they can call if that happens. When asked if she ever called 911, V15 stated she had many times. V15 stated she would call 911 if it was an emergent situation. When asked what the difference was in calling an ambulance service direct and calling 911, V15 stated she wasn't sure what it meant to them but to the facility it meant they needed someone at the facility now. On 10/12/23 at 3:35 PM, this surveyor reviewed R1's progress notes dated 10/04/23 with V3 (Assistant Director of Nursing/ADON). At that time V3 stated she would have called the doctor to see what they wanted her to do. On 10/16/23 at 10:36 AM, V3 (ADON) stated she worked the night shift beginning on 10/03/23 and didn't come to the facility on [DATE] until around 9:00 AM. V3 stated she was told R1 had died at that time. V3 stated she was told they couldn't get R1's body temperature up and they called the doctor and were told to send R1 to the hospital. V3 stated they told her R1 was talking to them when she left the facility. This surveyor reviewed the symptoms documented in R1's progress notes and asked V3 if she would consider them emergent. V3 stated, Yes, that could be signs of stroke. This surveyor reviewed with V3 the delay in an ambulance arriving to the facility and asked what her expectation would be and V3 stated she would have called all the ambulance services and if they weren't available, she would have called 911. On 10/16/23 at 10:24 AM, V2 (DON/Director of Nurses) stated it was not the facility's normal procedure to wait for an ambulance. V2 stated she would have called 911 if she had been at the facility. V2 stated it isn't uncommon for the ambulance service to say they don't have a crew available. V2 stated most people they send to the hospital are not in emergent situations. When asked what the normal process is, V2 stated the facility staff should call the ambulance listed on the resident chart and then call other services if the residents preference provider is not available. When asked why they didn't just call 911, V2 stated most of the time it is non-emergent, so she thinks staff are just used to calling the ambulance service direct. V2 stated she was not aware of the delay for R1. On 10/16/23 at 11:08 AM, V1 (Administrator) stated she wasn't involved in R1's transfer to the hospital on [DATE]. V1 stated she knew R1 was supposed to go out for a new chemotherapy line and had been without food and drink through the night for the procedure. V1 stated she knew R1 wasn't doing well and had been in a slow decline. V1 stated they wondered why the physician was putting her through the treatment when the outcome wasn't going to be good. V1 stated but she knew R1 wanted to fight. V1 stated she read the hospital medical records and that R1 had coded on her way to the hospital. V1 stated she got statements from V12 (CNA) and V25 (PTA) who was working. V1 stated V25 was walking another resident when she heard R1 holler out and said she was hurting everywhere. V1 stated this happened at 7:00 AM so she knew R1 was talking at that time. V1 stated she called the ambulance supervisor and talked with him. V1 stated she thought that ambulance service was their 911 ambulance. V1 stated the ambulance supervisor said they were the 911 ambulance service but there was also one in another nearby town. V1's investigation provided to this surveyor, included statements from V12 and V25, a copy of R1's hospital record that documented, From NH (nursing home) EMS states she was down since 6am when EMS arrived her pupils were fixed and dilated. CPR in process when EMS arrived (to hospital). This hospital record had handwritten at the bottom, Talked with (name of person) at (name of ambulance service) stated EMS denied statement that she was down since 06:00 (6:00 AM)- Last well time was 06 (6:00 AM). V1's investigation also included a copy of R1's progress notes from 10/04/23. There was no outcome or interventions documented in investigation. On 10/19/23 at 10:19 AM, V1 (Administrator) was asked via email if she had provided this surveyor with her full investigation and if there were any interventions implemented after her investigation. V1 responded, That was my investigation at that time. V1 stated she also called the manager at the ambulance service and discussed R1's transfer and asked him if they were other 911 ambulance services and the manager replied they were. V1 stated in the email she asked him if they were not available who should they call, and the manager named another local ambulance service, and she asked if that service was unavailable who should they call. V1 stated he said if they called 911 it would be another close town's ambulance if no one else was available. V1 stated she shared the information with the team and plans were made to review charts. V1 stated they completed that review on 10/11/23. V1 stated V2 (DON) scheduled a meeting with the nurses on 10/17/23 to explain to call 911 for emergencies and to call the resident ambulance choice for non-emergencies. On 10/18/23 at 11:49 AM, V5 (ambulance dispatcher) stated they notify the facility 100% of the time if they don't have a crew available. V5 stated they tell them they need to call for mutual aid. V5 stated they have two other options in the town that would be immediate responses. When asked what the difference was for someone to call 911 versus calling the ambulance direct, V5 stated if someone calls 911 that call goes to the police department dispatch and then they tone out this ambulance service. V5 stated if this ambulance service doesn't have a crew available, they tone out the next ambulance service and if they don't have a crew available, they tone out the next ambulance service. On 10/16/23 at 9:49 AM, V24 (Nurse Practitioner) stated she remembered getting the call on 10/04/23 related to R1's symptoms and she told them to send her to the emergency room for evaluation and treatment. V24 stated she got the call in the early morning but didn't have the time documented anywhere. This surveyor reviewed R1's progress notes and the staff interviews with V24 including the time frames. V24 stated she wasn't aware of the delay in treatment. V24 stated even if V14 didn't think it was emergent when the symptoms first started, she should have quickly realized it was. V24 stated based on what she read in R1's record it was a significant bleed that appeared to be spontaneous. V24 stated based on that she couldn't say the outcome for R1 would have been different if she had received timely care. V24 stated R1's symptoms were emergent, and she would have expected the facility to call 911. On 10/16/23 at 9:03 AM, V18 (Cancer Specialist) stated R1 had pancreatic cancer and her cancer treatment was palliative in nature, to help prevent pain and discomfort. V18 stated R1 was on Xarelto and that could increase her risk of bleeding. When asked if R1 had received treatment quicker if the outcome could have been different V18 stated, with a GI bleed the quicker the treatment the better. V18 stated he couldn't guarantee it would have made a difference in the outcome. V18 stated she couldn't be off the Xarelto due to her diagnosis, and he couldn't judge if quicker treatment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify a decline in condition as an emergent situation and ensure a system was in place to obtain timely emergency transport for 3 of 6 (R1, R8, and R9) residents reviewed for hospital transfers in the sample of 9. This failure resulted in R1 not being transported to the hospital emergency room for an hour while experiencing worsening symptoms of sluggish dilated pupils, temperature of 95.7, difficulty with speech, slow response time, and facility staff were unable to obtain an oxygen saturation. R1 expired in the hospital emergency room and cause of death is documented as a massive gastrointestinal bleed. This failure has the potential to affect all 37 residents residing at the facility. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 10/04/23 when the facility failed to ensure R1 received timely medical care when they failed to recognize an emergent situation and call 911 after the ambulance provider they called was delayed. This failure resulted in R1 remaining at the facility from 6:39 AM until the ambulance arrived at 7:35 AM with worsening symptoms. R1 was subsequently transferred to the local hospital, went into cardiac arrest during transfer, and expired in the hospital emergency room on [DATE]. R1's cause of death is documented as a massive gastrointestinal (GI) bleed. V1 (Administrator) was notified of the Immediate Jeopardy on 10/17/23 at 9:14 AM. The surveyor confirmed by record review and interview, that the Immediate Jeopardy was removed on 10/17/23 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training. Findings Include: 1. R1's admission Record with a print date of 10/12/23 documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, malignant neoplasm of pancreas, atrial fibrillation, restless leg syndrome, neuromuscular dysfunction of bladder, major depressive disorder, cognitive communication deficit, and weakness. R1's MDS (Minimum Data Set) dated 7/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 was cognitively intact. R1's Order Summary Report with active orders as of 9/30/23 documents a physician order that R1 was a full code and a physician order for Xarelto 20 milligrams (mg) one every afternoon. R1's Care Plan documents a Focus area with a created date of 6/30/23 documents, Usage of black box medications: .Xarelto . The interventions documented for this Focus area include, Monitor and assess for side effects of medications that contain black box warning PRN (as needed). R1's Care Plan documents a Focus area with a created date of 6/27/23 of, (R1) wishes to return home with (name of home health agencies). The intervention documented for this Focus area is, Evaluate and discuss with the (R1) and (V19) the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits, and needs for maximum independence. R1's Power of Attorney for Health Care dated 6/27/23 documents V19 (family member/spouse) was R1's agent to make decisions for her when she was not able to make them for herself. The form documents a check mark next to the following statement, Staying alive is more important to me, no matter how sick I am, how much I am suffering, the cost of the procedures, or how unlikely my chances for recovery are. I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical standards. R1's Social Services Assessment and Note dated 6/27/23 documents under Social Service Note, (R1) was admitted to (name of facility) for a short-term therapy stay following a long hospitalization. POLST (Physician Orders for Life Sustaining Treatment) FULL CODE per choice. HCPOA (Health Care Power of Attorney) husband (V19) 6/26/23 . R1's Progress Notes document the following: 10/03/23 2:20 PM, resident (R1) is alert, verbal, oriented x 2, sleeps well at night. 10/04/23 6:50 AM, AM ADL's (activities of daily living) to go get chemo (chemotherapy) port placement this am. Res (R1) has been NPO (nothing by mouth). CNA (Certified Nursing Assistant) called this writer (V14) to room. (R1) having difficulty with speech et (and) slow to respond. CNAs stated at oncome of shift at 0600 (6:00 AM) was talking fine. Pupils sluggish to response, dilated. Bilat (bilateral) upper ext. (extremity) edema. Unable to get O2 sat (saturation), pale but no discoloration. Blanches pink nail beds, flaccid strength per her norm, total assist, blankets applied to increase temp (temperature) skin cool, 95.7 122/88, 84, 20 room air. Called (V24/NP-Nurse Practitioner) send to ER (emergency room) for evaluation r/t (related to) condition change. (Name of ambulance service) called at 0655 (6:55 AM) called husband and made aware of. This writer staying by room to monitor. This progress note was signed by V14 (LPN/Licensed Practical Nurse). 10/04/23 7:35 AM, (ambulance service) here. 0745 (7:45 AM) Exit with (R1) per transfer of 4 to stretcher. 10/04/23 10:15 AM, husband here et made aware of wife expiring. Hugged this nurse et stated thank you for taking good care of her. Belongings taken at this time. Administrators present with facilities (sic) condolences. Called (V24) et made aware of (R1) expiring per notification from husband. R1's Ambulance Patient Care Report dated 10/04/2023 documents under Response Information the Nature of Call as Medical Emergency and documents, Caller (Uncooperative) No EMS (Emergency Medical Service) Vehicles (Units) Available. Under Times the report documents, Injury: 0659 (AM) .Recvd (received) 06:59 (AM) .Dispatch: 07:35 (AM) . The Patient Care Report documents Altered Consciousness-Unresponsive as the chief complaint. Under Narrative the report documents, Responded emergent for a direct call to (name of facility) report of a female with flaccid, decline in responsiveness, and uneven pupils. Per dispatch nursing home refused to call 911 and wanted to wait for (name of ambulance service) ambulance knowing it (sic) we don't have any units available and will be a while. Delay to scene due to no units available. AOS (arrived on scene) to find pt (patient/R1) laying in nursing home bed. Per nursing home staff, staff noticed a change in (R1's) condition around 0600 (6:00 AM) this morning when they started their shift. Further, nurse states (R1's) temperature is 95.4 and they are attempting to warm her. (R1) is unresponsive, pale, cool, and clammy. (R1) moved to cot, secured, and loaded into ambulance. (R1) has a PICC (peripherally inserted central catheter) line to her left upper arm. (R1) placed on cardiac monitor showing sinus bradycardia, (R1) went into cardiac arrest. CPR (Cardiopulmonary Resuscitation) immediately started by (names of paramedics and emergency medical technician) contacted (name of local hospital) ED (Emergency Department) to given (sic) (R1) update upon arrival. Pads placed on (R1) showing asystole. ER (Emergency Room) staff met this unit outside and assisted in taking (R1) into emergency room .(R1) care left with ER nursing staff R1's local hospital emergency department record dated 10/04/23 documents under History, Chief Complaint Patient (R1) presents with Cardiac Arrest. Pt (R1) per EMS (emergency medical services) has been told by NH (nursing home) staff unresponsive since 0600 (6:00 AM) . they were called just pta (prior to arrival) and found (R1) unresponsive hr (heart rate) 30's in route just across street full arrest they started cpr (cardiopulmonary resuscitation) large amt (amount) of black vomit on arrival asystole on arrival accu (sic) done by us 84 on arrival, cpr continued going thru epi (epinephrine) x (times) 3, attempted intubations very large vomit in airway clogging up many yankars with blood clots difficult to get clear site, unable to pass 7 tube ? (question) mass beyond tried 6.5 still unable getting video stylet unable to see, anesthesia called but placed lma (laryngeal mask airway) and b/l (bilateral) bs (breath sounds) after still asystole and (R1) pupils fixed dilated on arrival pale waxy color entire time and US (ultrasound) cardiac no activity no pulse called tod (time of death) at 0808 (8:08 AM). Under Physical Exam R1's hospital record documents, BP (blood pressure) 56/38, SpO2 85% .fixed and dilated pupils .pulse with cpr then nothing .bagging after lma b/l bs. R1's hospital record documents Cardiac Arrest under ED (Emergency Department) Course, Clinical Impressions. R1's Certificate of Death Worksheet documents R1 expired on 10/04/23 and Cause of Death is documented as Massive Gastrointestinal Bleed. On 10/11/23 at 4:17 PM, V12 (CNA) stated she provided care to R1 on 10/02, 10/3, and 10/04/23. V12 stated on 10/2 and 10/3/23, R1 refused to eat and didn't want to get out of bed on those days. V12 stated R1 wasn't talking as loud, she was kind of quiet and mumbly (sic). V12 stated she came to work on 10/04/23 and it was reported to her by night shift, R1 had complained of not feeling well through the night. V12 stated she went straight to R1's room after she got report at 6:00 AM. V12 stated she told V14 (LPN/Licensed Practical Nurse) to assess R1. V12 stated V14 first said she was going to send R1 out to the hospital for evaluation and then changed her mind and had them get R1 up to go to the appointment she had. V12 stated they got R1 up and took her to the nurse's station. V12 stated they took R1's temperature and it was around 95.0. V12 stated, V14 told them to put R1 back to bed they were calling the ambulance. V12 stated V14 told them it was going to be a little bit before the ambulance could get there because they had someone going out on a helicopter. V12 stated at that point R1 was cold and was still speaking and told them she was hurting all over. V12 stated then R1 was kind of hollering and yelling. V12 stated, V25 (PTA/Physical Therapy Assistant) went in to check on R1 and R1 told V25 she was hurting all over. V12 stated she checked on R1 around 7:00 AM and at that time R1 was not able to verbally communicate with words. V12 stated the ambulance got to the facility around 7:30 AM. V12 stated R1 was alert but they couldn't get her to speak at that point. V12 stated the ambulance crew asked V14 as soon they got in the room why she refused to call 911. V12 said V14 told the ambulance crew as far as she knew there were no ambulances. On 10/16/23 at 11:28 AM, V25 (PTA) stated she was walking another resident down the hall when she heard R1 screaming and yelling, help me, help me. V25 stated she finished walking the resident down the hall and went back to check on R1. V25 stated she asked R1 if she was ok and R1 didn't respond. V25 stated R1 was looking up at the ceiling so she asked R1 if she was hurting. V25 stated R1 said yes and when she asked her where she was hurting R1 screamed, everywhere. When asked if that was normal behavior for R1, V25 stated, no. V25 stated she had never heard R1 scream out like that. V25 stated R1 was definitely not a screamer. V25 stated R1 was hollering and V25 mimicked a continuous holler. V25 stated at first there were no words and then R1 yelled the word, everywhere. V25 stated she thought this was around 6:30 AM then stated it was between 7:15 and 7:30 AM. V25 stated she reported it to the V14 (LPN). V27 stated an unknown CNA told her they had already contacted the ambulance and they were just waiting on the ambulance to get free to come get R1. On 10/11/23 at 3:27 PM, V9 (CNA) stated she provided care to R1 in the days leading up to 10/04/23 and was working when R1 was sent to the hospital. V9 stated R1 had progressively gotten worse in the three days prior to 10/04/23. V9 stated she got to work on the morning of 10/04/23 around 5:50 AM. V9 stated R1 had an appointment scheduled for that morning so she and another CNA (V12) went to R1's room around 6:10 AM. V9 stated R1 was really out of it. V9 stated they reported it to the nurse (V14). V9 stated V14 told them to get R1 up so she could go to her appointment, so they did. V9 stated they took R1 to the nurse's station and R1 was very cold. V9 stated V14 told them to put R1 back to bed and they were sending R1 to the hospital. When asked how long it took the ambulance to arrive, V9 stated she knew it was a whole big ordeal. V9 stated she knew they called the ambulance, and they said it was going to be awhile before they could get to the facility. V9 was not able to say when the ambulance arrived. V9 stated she remembered R1 yelling and just trying to talk while V9 was trying to get other residents up. V9 stated she kept going in R1's room to check on her. V9 stated R1 was trying to talk but couldn't get her words out, but she was yelling and mumbling. V9 stated R1 worsened because she was able to say her name when she first saw her around 6:10 AM. When asked if a nurse was with R1 during this time frame, V9 stated, not the whole time but she was in the room multiple times. On 10/12/23 at 9:38 AM, V14 (LPN) stated she provided care to R1 on 10/04/23. V14 stated she started her shift at 6:00 AM and went to R1's room around 6:05 AM. V14 stated right after that V9 and V12 (CNA's) reported to her R1 was acting different. V14 stated she assessed R1 including checking her vital signs and R1's blood pressure was 122/88. V14 stated R1 was sluggish to respond but was vocal at that time. V14 stated R1's temperature was 95.7 Fahrenheit and hypothermic measures were implemented such as extra blankets. V14 stated R1 was full of fluid but blanched pink when she blanched her. V14 stated she called the ambulance service direct around 6:15 AM and told them R1 was sluggish to respond and slurring her words, a change from 10 minutes prior. V14 stated the ambulance service told her they would send someone out. V14 stated she then went to R1's room and stayed with her. V14 then stated she passed medications to other residents on the same hallway. When asked if that meant she wasn't with R1 the whole time, V14 stated, No, not the whole time. V14 stated R1 looked as though she was resting. When asked when the ambulance service arrived, V14 stated, V20 (RN/Registered Nurse) hollered down and told her there were two helicopters and all the ambulance crews were tied up, so that delayed them from arriving at the facility. V14 stated she would guess they arrived at the facility around 7:15 or 7:20 AM. V14 stated she didn't call 911. V14 stated she didn't realize she had an emergent situation. V14 stated R1 had a condition change and she wanted her out of the facility as fast as she could go but didn't think she was going to pass away. V14 stated the normal procedure for sending a resident to the hospital is to call the ambulance service direct. V14 stated she thought calling them would be her fastest response. On 10/11/23 at 4:31 PM, V13 (EMT/Emergency Medical Technician, Basic) stated she transported R1 from the facility to the local hospital on [DATE]. V13 stated it was unusual because R1's call came while she was on another call. V13 stated she was on the helipad and the patient she was working with had a soft blood pressure so the helicopter couldn't leave. V13 stated when that happens the ground crew can't leave the helipad. V13 stated she got the call around 6:39 AM from the night shift dispatcher (V27) that there was a resident (R1) at the facility with uneven pupils, flaccid, unresponsive, and sitting at the nurse's station. V13 stated she responded to dispatch to call the facility and tell them to call another service because with those symptoms they needed immediate transport, and the other crew was in another city on a different transport. V13 stated she returned to the helipad, and she got another call from dispatch at around 7:00 AM. V13 stated dispatch told her the resident (R1) was still waiting for transport. V13 stated she explained to dispatch R1 couldn't wait. V13 stated they finished at the helipad around 7:35 AM and when they called in that the call, they were on was complete, they were told the resident (R1) was still waiting for transport at the facility. V13 stated they went in route to the facility and arrived within less than two minutes. V13 stated the nurse (V14) told them R1 was in bed, and they were trying to warm her since her temperature was 95.4. V13 stated they asked her why she didn't call 911 and V14 told them she was busy on the hall. V13 stated when they got to R1's room she was in bed laying under a blanket. V13 stated R1 was diaphoretic, cold to touch gray/blue around her lips and outside her mouth, both pupils were dilated, and the left pupil measured a 6 while the right pupil was an 8. V13 stated facility staff helped transfer R1 to the cot and they started oxygen immediately. V13 couldn't remember if oxygen had been applied by the facility staff prior to their arrival. V13 stated once in the ambulance her partner attempted to start an IV (intravenous access) and they were unable to get a blood pressure. V13 stated then R1 went loose and lost her pulse. V13 stated they started CPR and R1 was spewing coffee ground emesis with compressions. V13 stated they were in route to the hospital which is less than two minutes away and they turned her care over to the ER staff when they arrived. On 10/13/23 at 4:04 PM, V27 (Dispatcher, Ambulance Service) stated she works at the ambulance service as a dispatcher on the 11 PM to 7 AM shift. V27 stated she received a call from the facility around 6:39 AM on 10/04/23 and the nurse (V14) gave her the information on R1. V27 stated she told V14 there was no crew available because they had a crew going to a regional hospital and one on the helipad. V27 stated V14 said she guessed she would wait for them. V27 stated she called the crew to get an established time frame and they said it would be 30-40 minutes. V27 stated she called the facility back around 7:00 AM to make them aware of the time frame. V27 stated she didn't get the name of the nurse who answered the phone, but she told them the time frame and they said they would let the nurse know. V27 stated it took the crew approximately 30 minutes after that to get to the facility. On 10/11/23 at 12:02 PM, V5 (Ambulance Dispatcher) stated he came on duty on 10/04/23 at 7:00 AM. V5 stated the original call came from the facility at 6:39 AM. V5 stated they had one ambulance crew out of town doing a run and a second crew working on the helipad with a stroke victim. V5 stated the night shift dispatcher (V27) called the facility back at 7:02 AM and told them it was still going to be thirty minutes before they could arrive to the facility to transport R1 to the local hospital. V5 stated the facility said they would wait. V5 stated the crew arrived at the facility at 7:35 AM. On 10/18/23 at 11:22 AM, when asked why the time on R1's ambulance report is documented as 6:59 AM when all the interviews say the first call came from the facility at 6:39 AM, V5 (ambulance dispatcher) stated the original call came in at 6:39 AM but they didn't create the call in the system because they didn't know if they would be taking the call. V5 stated they didn't create the call in the system until they talked to the crew and called the facility back. V5 stated he took a picture of the time the calls came in and the original call's picture shows it was 6:3*, with the last number not visible. V5 stated the time stamp on the call logs shows the ambulance service called the facility back at 7:02 AM. On 10/12/23 at 11:19 AM, V17 (LPN) stated she was working the day R1 was sent to the hospital. V17 stated they were getting ready to start morning medication pass, and the CNA's brought R1 up for breakfast. V17 stated V14 (LPN) said she was going to send R1 out to the hospital. V17 stated they took R1 to her room and V17 started passing medications. V17 stated the ambulance service called back and said they were 20-30 minutes out. V17 stated she remembered calling that information down to V14. V17 stated she talked to R1 on her way out the door and told her goodbye. When asked if R1 responded to her, V17 stated she couldn't remember. On 10/12/23 at 1:37 PM, V20 (RN) stated she works night shift and on the morning of 10/04/23 she gave report to the oncoming nurse (V14) at approximately 6:00 AM. V20 stated V14 brought R1 to the nurse's desk and V14 said something was wrong with R1. V20 stated it was a change in condition from when she had seen R1 around 2:30 AM, when R1 was talking and asking to be repositioned. V20 stated V14 was having trouble getting R1's vital signs so she helped her and V14 called the ambulance. V20 stated she was working on paperwork when the ambulance called back, and she answered the phone. V20 stated they told her they were going to be about 30 minutes. V20 stated she told the other nurse (V17) and V17 told V14. V20 stated she finished her work and left, and the ambulance had not arrived at the facility when she left. When asked if it was typical for the ambulance to take an extra 30 minutes, V20 stated, At times they do, When asked what they normally do in those situations V20 stated she would either call another ambulance service or call 911. On 10/12/23 at 2:33 PM, V23 (CNA) stated she worked the night before R1 was sent to the hospital. V23 stated R1 was talking to her when she left the facility the morning of 10/04/23 at 6:00 AM. V23 stated R1 was very restless through the night shift and said she just didn't feel good and couldn't get comfortable. V23 stated R1's hands were very swollen and R1 couldn't use them. On 10/12/23 at 3:24 PM, V26 (CNA) stated she worked night shift beginning on 10/03/23 and leaving on the morning of 10/04/23. V26 stated R1 was very uncomfortable, R1's hands were swollen, and R1 seemed really nervous like she was scared or something. V26 stated R1 complained of a stomachache and so they gave her some tums and it helped. When asked how R1 was when she left the facility at 6:00 AM, V26 stated R1 had been up all night and was sleeping so she let her sleep. On 10/12/23 at 1:14 PM, V19 (family member) stated he saw R1 on 9/30/23 and 10/01/23. V19 stated R1 couldn't swallow and seemed kind of groggy. V19 stated the facility called him on 10/04/23 and told him they were transferring R1 to the hospital and then the hospital called him a lot later with an update. When asked what time the facility called him V19 stated he told V22 (family member). On 10/10/23 at 1:22 PM, V22 (family member) stated the facility called V19 on 10/04/23 at 6:30 AM and told V19, R1 was not acting right. V22 stated around 7:45 AM, R1 arrived at the hospital in cardiac arrest. On 10/11/23 at 3:01 PM, V6 (LPN) stated the typical time to transfer a resident to the hospital is thirty minutes or so if the ambulance is backed up. V6 stated it has taken longer. V6 stated it has taken up to an hour. When asked if there was another option for an ambulance service V6 stated the name of another ambulance service provider and stated but sometimes they don't come this way. V6 then stated, Honestly, if it came down to it, I would push them to the hospital. It is right next door. When asked who she calls when they need an ambulance V6 stated, if they are unresponsive, I call 911. When asked if she was providing care to R1 when she was transferred to the hospital on [DATE], V6 stated she was not. V6 stated, She (R1) wasn't one to give up. I was kind of shocked when I found out she had passed away. On 10/11/23 at 3:39 PM, V10 (LPN) stated she didn't provide care for R1. When asked what the process was to send a resident to the hospital V10 stated, they assess the resident, call the physician, get the orders, call the power of attorney, ambulance, and hospital. When asked how long this process takes V10 stated 15-20 minutes or less if there are two nurses working on it. V10 stated it usually takes the ambulance 5-10 minutes to arrive. On 10/12/23 at 10:07 AM, V15 (RN) stated the normal procedure for sending a resident to the hospital would be to assess the resident, call the doctor, if emergent she would get another nurse to get the paperwork started and call the ambulance. V15 stated if not emergent she would call the doctor, get the paperwork printed and get them sent out. V15 stated unless there is a delay with the ambulance it is a pretty speedy process. When asked what would cause a delay V15 stated the ambulance service sometimes says they don't have any crews available. V15 stated they have more than one ambulance service they can call if that happens. When asked if she ever called 911, V15 stated she had many times. V15 stated she would call 911 if it was an emergent situation. When asked what the difference was in calling an ambulance service direct and calling 911, V15 stated she wasn't sure what it meant to them but to the facility it meant they needed someone at the facility now. On 10/12/23 at 3:35 PM, this surveyor reviewed R1's progress notes dated 10/04/23 with V3 (Assistant Director or Nurses/ADON). At that time V3 stated she would have called the doctor to see what they wanted her to do. On 10/16/23 at 10:36 AM, V3 (ADON) stated she worked the night shift beginning on 10/03/23 and didn't come to the facility on [DATE] until around 9:00 AM. V3 stated she was told R1 had died at that time. V3 stated she was told they couldn't get R1's body temperature up and they called the doctor and were told to send R1 to the hospital. V3 stated they told her R1 was talking to them when she left the facility. This surveyor reviewed the symptoms documented in R1's progress notes and asked V3 if she would consider them emergent. V3 stated, Yes, that could be signs of stroke. This surveyor reviewed with V3 the delay in an ambulance arriving to the facility and asked what her expectation would be and V3 stated she would have called all the ambulance services and if they weren't available, she would have called 911. On 10/16/23 at 10:24 AM, V2 (DON/Director of Nurses) stated it was not the facility's normal procedure to wait for an ambulance. V2 stated she would have called 911 if she had been at the facility. V2 stated it isn't uncommon for the ambulance service to say they don't have a crew available. V2 stated most people they send to the hospital are not in emergent situations. When asked what the normal process is, V2 stated the facility staff should call the ambulance listed on the resident chart and then call other services if the residents preference provider is not available. When asked why they didn't just call 911, V2 stated most of the time it is non-emergent, so she thinks staff are just used to calling the ambulance service direct. V2 stated she was not aware of the delay for R1. On 10/16/23 at 11:08 AM, V1 (Administrator) stated she wasn't involved in R1's transfer to the hospital on [DATE]. V1 stated she knew R1 was supposed to go out for a new chemotherapy line and had been without food and drink through the night for the procedure. V1 stated she knew R1 wasn't doing well and had been in a slow decline. V1 stated they wondered why the physician was putting her through the treatment when the outcome wasn't going to be good. V1 stated but she knew R1 wanted to fight. V1 stated she read the hospital medical records and that R1 had coded on her way to the hospital. V1 stated she got statements from V12 (CNA) and V25 (PTA) who was working. V1 stated V25 was walking another resident when she heard R1 holler out and said she was hurting everywhere. V1 stated this happened at 7:00 AM so she knew R1 was talking at that time. V1 stated she called the ambulance supervisor and talked with him. V1 stated she thought that ambulance service was their 911 ambulance. V1 stated the ambulance supervisor said they were the 911 ambulance service but there was also one in another nearby town. V1's investigation provided to this surveyor, included statements from V12 and V25, a copy of R1's hospital record that documented, From NH (nursing home) EMS states she was down since 6am when EMS arrived her pupils were fixed and dilated. CPR in process when EMS arrived (to hospital). This hospital record had handwritten at the bottom, Talked with (name of person) at (name of ambulance service) stated EMS denied statement that she was down since 06:00 (6:00 AM)- 'Last well time was 06 (6:00 AM). V1's investigation also included a copy of R1's progress notes from 10/04/23. There was no outcome or interventions documented in investigation. On 10/19/23 at 10:19 AM, V1 (Administrator) was asked via email if she had provided this surveyor with her full investigation and if there were any interventions implemented after her investigation. V1 responded, That was my investigation at that time. V1 stated she also called the manager at the ambulance service and discussed R1's transfer and asked him if they were other 911 ambulance services and the manager replied they were. V1 stated in the email she asked him if they were not available who should they call, and the manager named another local ambulance service, and she asked if that service was unavailable who should they call. V1 stated he said if they called 911 it would be another close town's ambulance if no one else was available. V1 stated she shared the information with the team and plans were made to review charts. V1 stated they completed that review on 10/11/23. V1 stated V2 (DON) scheduled a meeting with the nurses on 10/17/23 to explain to call 911 for emergencies and to call the resident ambulance choice for non-emergencies. On 10/18/23 at 11:49 AM, V5 (ambulance dispatcher) stated they notify the facility 100% of the time if they don't have a crew available. V5 stated they tell them they need to call for mutual aid. V5 stated they have two other options in the town that would be immediate responses. When asked what the difference was for someone to call 911 versus calling the ambulance direct, V5 stated if someone calls 911 that call goes to the police department dispatch and then they tone out this ambulance service. V5 stated if this ambulance service doesn't have a crew available, they tone out the next ambulance service and if they don't have a crew available, they tone out the next ambulance service. On 10/16/23 at 9:49 AM, V24 (Nurse Practitioner) stated she remembered getting the call on 10/04/23 related to R1's symptoms and she told them to send her to the emergency room for evaluation and treatment. V24 stated she got the call in the early morning but didn't have the time documented anywhere. This surveyor reviewed R1's progress notes and the staff interviews with V24 including the time frames. V24 stated she wasn't aware of the delay in treatment. V24 stated even if V14 didn't think it was emergent when the symptoms first started, she should have quickly realized it was. V24 stated based on what she read in R1's record it was a significant bleed that appeared to be spontaneous. V24 stated based on that she couldn't say the outcome for R1 would have been different if she had received timely care. V24 stated R1's symptoms were emergent, and she would have expected the facility to call 911. On 10/16/23 at 9:03 AM, V18 (Cancer Specialist) stated R1 had pancreatic cancer and her cancer treatment was palliative in nature, to help prevent pain and discomfort. V18 stated R1 was on Xarelto and that could increase her risk of bleeding. When asked if R1 had received treatment quicker if the outcome could have been different V18 stated, with a GI bleed the quicker the treatment the better. V18 stated he couldn't guarantee it would have made a difference in the outcome. V18 stated she couldn't be off the Xarelto due to her diagnosis, and he couldn't judge if quicker treatment would have altered the ou[TRUNCATED]