**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and facility policy review, the facility failed to ensure treatment orders were implemented in a timely manner and/or completed as ordered. Actual Harm occurred on 02/04/25 when Resident #17, who was a paraplegic and was dependent on staff assistance for most activities of daily living (ADL) including transfers, and rolling left and right in bed, was found to have an in-house acquired Stage II pressure ulcer (partial- thickness skin loss appearing as a shallow area with a red or pink wound bed) to his sacrum (located at the base of the spine) that measured 3.5 centimeters (cm) in length by 1.9 cm in width by 0.2 cm in depth. The facility failed to implement the treatment as ordered on 02/04/25 of Medi Honey (a brand of medical-grade honey-based product used for wound management) and silicone bordered foam dressing daily until 02/07/25. Wound Nurse Practitioner (NP) #900 consulted on 02/11/25 and noted a significant decline to Resident #17's sacrum pressure ulcer as the wound increased in size to 11.0 cm in length by 5.2 cm in width by unable to determine the depth as the wound had 10 percent slough (dead tissue that accumulated on the surface of a wound) and 60 percent purple/ maroon discoloration. Wound NP #900 classified the pressure wound as unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin). The facility did not ensure ongoing treatments were completed as ordered and on 03/18/25, Resident #17's sacrum pressure ulcer was classified as a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) as the wound had bone that was palpable. In addition, Resident #17 had pressure ulcers to his right and left ankles and the treatments were not completed as ordered. This affected one (#17) of two residents reviewed for pressure ulcers. The facility census was 73. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 10/31/24 with diagnoses including paraplegia, diabetes, pressure ulcer to sacral region, and congestive heart failure. Resident #17 was on hospice when admitted with senile degeneration of the brain listed as his end stage diagnosis; however, hospice was discontinued on 01/08/25, and he had no other terminal/end stage diagnosis. Review of the care plan dated 11/04/24 revealed Resident #17 had actual skin impairment related to diabetic, arterial, and pressure ulcers. He preferred to be out of bed and lie on his back despite education. Interventions included initiating wound treatment and continuing treatment as ordered, limiting time out of bed, nursing to observe the wound dressing daily to ensure that the dressing remains intact and that there were no signs of infection, pressure reducing cushion to chair and pressure reducing mattress to bed. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition. He had impairment on both his lower extremities and required substantial to maximum assistance with toileting hygiene and showers. He was completely dependent on staff with rolling left and right and transfers. He was at risk for the development of pressure ulcers and had two unhealed Stage 3 (full-thickness skin loss extending to the subcutaneous tissue layer) pressure ulcers that were present on admission and one vascular ulcer. Review of the February 2025 treatment administration record (TAR) revealed Resident #17 had an order to his sacrum area to apply zinc barrier cream topically every shift and as needed dated from 10/31/24 to 02/06/25. The TAR was blank, indicating the treatment was not completed on dayshift 02/01/25, 02/02/25 and 02/06/25. The treatment order to his sacrum pressure ulcer was changed on 02/07/25, three days after Wound NP #900 had ordered to clean the wound with normal saline, pat dry, apply Medi Honey and cover with silicone foam dressing daily and as needed. The treatment order for Resident #17's sacrum pressure ulcer was changed on 02/12/25 to clean the wound with normal saline, pat dry, apply calcium alginate (absorbent sterile wound dressing used to manage moderate to heavy drainage from a wound), cover with silicone foam dressing daily and as needed. The TAR was blank, indicating the treatment was not completed on 02/18/25. The treatment order for Resident #17's sacrum pressure ulcer was changed on 02/19/25 to clean the wound with normal saline, pat dry, apply one fourth strength Dakin's (a solution for wound management for cleaning and debriding wounds) moistened gauze, and cover with silicone foam dressing daily and as needed. The TAR was blank, indicating that the treatment was not completed on 02/26/25 and 02/28/25. Review of the nursing note dated 02/03/25 and completed by Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #323 revealed Resident #17 had a new open area to his sacrum area. Wound NP #900 was notified and stated she would see Resident #17 in the morning (02/04/25). Review of the Skin Grid Pressure assessment dated [DATE] and completed by ADON/LPN #323 revealed Resident #17 had a new Stage 2 pressure ulcer to his sacrum that measured 3.5 cm in length by 1.9 cm in width by 0.2 cm in depth. The wound was described as a shallow open area with pink moist tissue with a thin biofilm (protective slimy layer on the wound surface) partially wiped away. The assessment noted adding Medi Honey for autolytic debridement (a wound care technique that used the patient's enzymes to break down and remove dead tissue). Review of Wound NP #900's progress note dated 02/04/25 revealed Resident #17 had a new in-house acquired Stage 2 partial thickness pressure ulcer to his sacrum that measured 3.5 cm in length by 1.9 cm in width by 0.2 cm in depth. The area was described as a shallow open area with pink moist tissue with thin biofilm that partially wiped away. A new order was received to cleanse the wound with normal saline, apply Medi Honey and silicone bordered foam dressing daily. She revealed the treatment was chosen for autolytic debridement, antimicrobial activity (substances ability to kill or inhibit the growth of microorganisms), and epithelization promotion (the process of repairing a wound). The progress note stated that Resident #17 and the nursing staff were educated on the importance of adhering to prescribed treatments and dressing changes to prevent infection. Review of the Skin Grid Pressure assessment dated [DATE] and completed by ADON/LPN #323 revealed Resident #17's pressure ulcer to his sacrum had a rapid decline with larger measurements, and the wound had dark purple tissue extending across the sacrum towards the rectal area. The wound was classified as an unstageable pressure ulcer and measured 11 cm in length by 5.2 cm in width and the depth was unable to be determined. Review of Wound NP #900's progress note dated 02/11/25 revealed nursing reported a decline to Resident #17's sacral pressure ulcer which was previously thought may be related to moisture, but upon assessment Wound NP #900 felt the wound was pressure. Wound NP #900 revealed the wound may be related to end-of-life skin failure such as Kennedy terminal ulcer (Resident #17 did not have a terminal diagnosis, and Wound NP #900 felt the wound had a high likelihood of healing). She described the wound as unstageable and measured 11.0 cm in length by 5.2 cm in width and unable to determine the depth. The wound bed contained 30 percent granulation, 10 percent slough, and 60 percent purple/maroon discoloration with moderate serosanguinous (drainage from the wound with a mixture of clear watery fluid and blood) drainage. She recommended changing the treatment to cleanse the wound with normal saline, apply calcium alginate and cover with silicone bordered foam dressing daily. She revealed the treatment was chosen for autolytic debridement and drainage management. Review of the March 2025 TAR revealed Resident #17 continued to have a treatment to his sacrum to clean with normal saline, pat dry, apply one fourth Dakin's moistened gauze and cover with silicone foam dressing daily and as needed from 03/01/25 to 03/11/25. The TAR was blank 03/07/25, 03/10/25, and 03/11/25, indicating the treatment was not completed as ordered. The treatment was changed to twice a day from 03/11/25 until 03/18/25, and the TAR was blank on dayshift 03/14/25, 03/15/25, 03/16/25, and 03/18/25, indicating the treatment was not completed as ordered. The treatment was changed on 03/18/25 to continue the same treatment (clean with normal saline, pat dry, apply one forth strength Dakin's moistened gauze, and cover with silicone foam dressing twice daily) except add zinc oxide cream to peri-rectum twice a day. The TAR was blank 03/20/25, 03/21/25, and 03/24/25, indicating the treatment was not completed as ordered. Review of Wound NP #900's progress note dated 03/18/25 revealed Resident #17's pressure ulcer was classified as a Stage 4 pressure ulcer that measured 12.5 cm in length by 8.5 cm in width by 4.0 cm in depth. The wound had undermining between ten o'clock and two o'clock that measured 5.1 cm and had ten percent slough. There was heavy thick green drainage with palpable bone in the center of the wound. Review of Wound NP #900's progress note dated 03/25/25 revealed Resident #17 had a Stage 4 pressure ulcer to his sacrum area that measured 12.2 cm in length by 6.4 cm in width by 4.0 cm in depth. The note revealed there was undermining between ten o'clock and two o'clock that measured 5.1 cm. The wound bed had 90 percent granulation and 10 percent slough. Wound NP #900 noted that the wound had improved as there was healing beefy red granulating tissue with minimal slough and that the wound was being evaluated for graft placement. She recommended the same treatment to continue cleansing with normal saline, pat dry, apply one fourth strength Dakin's moistened gauze, and cover with silicone foam dressing twice daily. Nursing to topically apply zinc oxide cream to peri-rectum twice a day. Observation of wound care on 03/26/25 at 8:33 A.M. completed by ADON/LPN #323 and Certified Nursing Assistant (CNA) #344 revealed a Stage 4 pressure ulcer to Resident #17's sacrum. ADON/LPN #323 described the wound as granulating tissue covering the wound bed with bone exposed. Interview on 03/26/25 at 11:58 A.M. with ADON/LPN #323 verified Resident #17's sacrum treatments per the February and March 2025 TARs: 02/01/25, 02/02/25, 02/06/25, 02/18/25, 02/26/25, 02/28/25, 03/07/25, 03/10/25, 03/11/25, dayshift 03/14/25, 03/15/25, 03/16/25, 03/18/25, 03/20/25, 03/21/25, and 03/24/25 were blank, indicating the treatment was not completed as ordered. ADON/LPN #323 verified Wound NP #900 evaluated Resident #17's new facility acquired pressure ulcer to his sacrum on 02/04/25 and classified the wound as a Stage 2, and that he received a treatment order to cleanse the wound with normal saline, apply Medi Honey and cover with silicone bordered foam dressing daily. He verified the treatment was not transcribed and implemented until 02/07/25 per the physician orders/TAR. He verified from 02/04/25 to 02/11/25 Resident #17's wound significantly declined from a Stage 2 that measured 3.5 cm in length by 1.9 cm in width by 0.2 cm in depth to an unstageable pressure wound that measured 11 cm in length by 5.2 cm in width and unable to determine the depth as it contained ten percent slough, and 60 percent purple/maroon discoloration. He verified the wound then became a Stage 4 with bone exposed. Interview on 03/17/25 at 1:32 P.M. with Wound NP #900 revealed she was not aware that the treatment that she had ordered on 02/04/25 for Resident #17 was not initiated until 02/07/25. She verified the wound had declined rapidly from 02/04/25 to 02/11/25 from a Stage 2 to an unstageable pressure ulcer. She also verified she was not aware that the treatments were not being documented as completed as ordered. She verified the wound as of 03/25/25 was a Stage 4. 2. Review of medical record for Resident #17 revealed an admission date of 10/31/24 with diagnoses including paraplegia, diabetes, pressure ulcer to sacral region, and congestive heart failure. Review of Wound NP #900's progress note dated 11/05/24 revealed Resident #17 had a right lateral ankle Stage 3 pressure ulcer present on admission that measured 3.0 cm in length by 2.5 cm in width by 0.3cm in depth. The wound bed contained 90 percent granulation and 10 percent slough. Resident #17 had a Stage 3 pressure ulcer to his left lateral ankle that measured 1.2 cm in length by 0.5 cm in width by 0.3 cm in depth and the wound bed had 100 percent granulated tissue. Review of February 2025 TAR revealed Resident #17 had an order from 12/25/24 to 02/18/25 to cleanse his left lateral ankle with normal saline, pat dry, apply calcium silver alginate, cover with bordered foam dressing daily and as needed. The TAR was blank 02/01/25, 02/02/25 and 02/18/25, indicating the treatment was not completed as ordered. The treatment to his left lateral ankle was changed on 02/19/25 to cleanse with normal saline, pat dry, apply Skin Prep and leave open to air daily and as needed. The TAR was blank 02/20/25, 02/24/25, and 02/25/25, indicating the treatment was not completed as ordered. The TAR revealed Resident #17 had an order dated 12/25/24 till 02/11/25 to his right lateral ankle to cleanse with normal saline, pat dry, apply calcium alginate silver, ABD, and wrap with Kerlix gauze daily and as needed. The TAR was blank 02/01/25, 02/02/25, and 02/11/25, indicating the treatment was not completed as ordered. The treatment was changed on 02/19/25 to cleanse his right lateral ankle with normal saline, pat dry, apply moistened collagen, abdominal (ABD), wrap with Kerlix gauze daily and as needed. The TAR was blank 02/20/25, 02/24/25, and 02/25/25, indicating the treatment was not completed as ordered. Review of March 2025 TAR revealed Resident #17 had an order from 02/27/25 till 03/04/25 for his left lateral ankle pressure ulcer to cleanse with normal saline, pat dry, apply Skin Prep and leave open to air and as needed every Tuesday, Thursday and Saturday. The TAR was blank 03/01/25, indicating the treatment was not completed as ordered. The treatment to his right lateral ankle dated from 02/27/25 to 03/04/25 to cleanse with normal saline, pat dry, apply moistened collagen, ABD, wrap with Kerlix gauze every Tuesday, Thursday, Saturday, and as needed. The TAR was blank on 03/01/25 and 03/04/25, indicating the treatment was not completed as ordered. The treatment to his right lateral ankle was changed on 03/05/25 to cleanse with normal saline, pat dry, apply calcium silver alginate, ABD, wrap with Kerlix gauze daily and as needed. The TAR was blank on 03/07/25, 03/10/25, 03/11/25, 03/14/25, 03/15/25, 03/16/25, and 03/18/25, indicating the treatment was not completed as ordered. The treatment to his right lateral ankle was changed on 03/19/25 to cleanse the wound with normal saline, pat dry, apply Skin Prep daily and as needed. The TAR was blank on 03/21/25 and 03/24/25, indicating the treatment was not completed as ordered. Review of Wound NP #900's progress note dated 03/04/25 revealed the left lateral ankle was healed. Wound NP #900's progress note dated 03/25/25 revealed Resident #17's right lateral Stage 3 pressure ulcer was healed. Interview on 03/26/25 at 11:58 A.M. with ADON/LPN #323 verified all the above times the treatment on February 2025 and March 2025 TAR the treatment was not documented as completed as the TAR was blank. Review of the facility policy labeled, Pressure Injury Prevention and Management, dated 01/08/25, revealed the facility was committed to the prevention of avoidable pressure injuries and would provide treatment and services to heal pressure ulcers, prevent infection and prevent the development of additional pressure ulcers. The policy revealed treatments would be provided for all residents who have a pressure ulcer present. The policy revealed interventions would be documented in the care plan and communicated to all relevant staff. This deficiency represents non-compliance investigated under Master Complaint Number OH00163991, Complaint Numbers OH00162697 and OH00161917.

Based on closed record review, review of facility policy and interview, the facility failed to ensure Resident #70's change of condition was identified and addressed timely. Actual Harm occurred on 02/10/23 when nursing staff failed to timely evaluate and provide intervention for an acute change in Resident #70's condition. On 02/10/23 in the A.M., therapy staff found Resident #70 to be very lethargic, hard to arouse, and profusely sweating. However, the physician and/or nurse practitioner was not notified until 02/10/23 at 8:13 P.M. of the resident's change in condition. On 02/10/23 at 8:13 P.M. Resident #70's blood pressure was 86/54 (hypotensive) and he was transported to the local Emergency Department via EMS (Emergency Medical Services). The resident was admitted to the hospital with diagnoses of sepsis and acute kidney injury. This affected one resident (Resident #70) of three resident's reviewed for change of condition. The facility census was 68. Findings include: Review of Resident #70's medical record revealed an admission date of 02/08/23 and a discharge date of 02/10/23. Resident #70's diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, obstructive sleep apnea and type two diabetes mellitus. Review of Resident #70's Gold Form Provider Orders dated 02/08/23 included admitting diagnosis of intracerebral hemorrhage (stroke) and additional diagnoses calf deep venous thrombosis (DVT), gastric bypass status for obesity and presence of inferior vena cava filter. Resident #70 was a full code. Resident #70 spent time in the intensive care unit, and was on a ventilator during the hospitalization. Care recommendation was for inpatient care at a skilled nursing facility and hospital therapy services recommended therapy in a skilled nursing facility to work on rebuilding Resident #70's strength. Resident #70's prognosis was good and rehab potential, function was to improve. Review of Resident #70's admission Assessment with Baseline Care Plan dated 02/08/23 included Resident #70 was admitted from the hospital and had the cognitive ability to be oriented to his room and surroundings. Resident #70 was oriented to the room, call bell, bed controls and side rails. Resident #70 was alert to person and situation and had clear verbal communication. Resident #70 was non ambulatory. Review of Resident #70's care plan dated 02/09/23 included Resident #70 had the potential for complications related to cerebrovascular accident (CVA), as evidenced by cognitive impairment, communication impairment, and decline in activity of daily living (ADL) abilities. Interventions included physical therapy (PT), occupational therapy (OT) and speech therapy (ST) evaluation and treatment per orders; report to physician, nurse practitioner an ADL decline, increased confusion, memory loss, or delirium and increased communication problems. Review of Resident #70's PT Evaluation and Plan of Treatment note dated 02/09/23 included Resident #70 demonstrated excellent rehab potential as evidenced by high prior level of function (PLOF), ability to follow multi-stop directions, strong family support and able to make needs known. Review of Resident #70's nursing progress note on 02/10/23 at 12:23 A.M. included Resident #70 was alert. Review of Resident #70's Blood Pressure Summary on 02/10/23 at 12:24 A.M. revealed Resident #70's blood pressure was 137/76. Another blood pressure was not documented until 02/10/23 at 8:05 P.M. at which time the resident's blood pressure was 86/74 (hypotensive). Review of Resident #70's Speech Therapy Treatment Encounter Note dated 02/10/23 included lemon glycerin swabs were used to stimulate swallow function by placing pressure on the lingual groove with swallow 4/12 swabs. Resident #70 produced weak voicing with decreased volume, was oriented to 0, auditory comprehension was severely reduced and Resident #70 was unable to complete the entire evaluation. The notes were signed on 02/10/23 at 1:35 P.M. Review of Resident #70's Occupational Therapy Treatment Encounter Note dated 02/10/23 included Resident #70 had decreased alertness, needed repeated verbal cues and sternal rubs to try and arouse. Resident #70 was sweating profusely on this date. The note indicated: Nursing aware and blood sugars recorded. Family stated Resident #70 often sweated profusely and blood sugars generally were not low. The OT notes were signed on 02/10/23 at 3:01 P.M. Review of Resident #70's Physical Therapy Treatment Encounter Notes dated 02/10/23 included attempted to stand Resident #70 in the sit to stand lift with 100 percent cues and tactile cues to stand up. Resident #70 was very lethargic and hard to arouse this date. Resident #70 could not stand in the sit to stand lift. Sitting balance at the edge of the bed was poor to fair, balance was noted. Resident #70 required cues to maintain upright position in sitting. The PT note was not signed until 02/11/23 at 7:15 P.M. Review of Resident #70's progress notes written by Nurse Practitioner (NP) #306 dated 02/10/23 at 8:00 A.M. revealed Resident #70 was sitting in a chair in no acute distress, Family Member #308 was visiting and assisted with Resident #70's medical history. Resident #70 was able to talk but currently was tired and only able to answer yes or no to questions. Resident #70 was able to follow simple commands. NP #306 was not in the facility on 02/10/23 at 4:54 P.M. but documented at 4:54 P.M. Resident #70's blood pressure was 137/76, pulse 78, respirations 18, temperature 97.9 Fahrenheit, and oxygen saturation was 97 percent on room air. The vital signs matched the vital signs recorded in Resident #70's medical record on 02/10/23 at 12:24 A.M. The progress notes did not include therapy concerns as documented on 02/10/23 regarding Resident #70 being very lethargic, hard to arouse, and sweating profusely. Review of Resident #70's medical record revealed no additional progress notes form the last nursing progress note on 02/10/23 at 12:23 A.M. to indicate the resident was assessed after the change in condition noted by therapy staff. There was no evidence the physician or NP were notified of the change in resident condition. Review of blood sugars recorded in the medical record on 02/10/23 revealed there were no blood sugars recorded for Resident #70 until 02/10/23 at 8:07 P.M. when Resident #70 was transported via EMS services to the local hospital Emergency Department. Review of Resident #70's nursing progress notes dated 02/10/23 at 8:13 P.M. documented by Licensed Practical Nurse (LPN) #284 revealed Resident #70's family called him into the room because they were concerned about Resident #70's condition. Resident #70 was diaphoretic and cold to the touch, his blood pressure was 84/68, pulse 64, respirations 16, and temperature was 97.4 Fahrenheit. Nurse Practitioner (NP) #306 was contacted, and the family was adamant about having Resident #70 sent to the hospital Emergency Department for evaluation. NP #306 agreed to have resident #70 sent to the Emergency Department and 911 was called. Review of Resident #70's Prehospital Care Report Summary dated 02/10/23 included a call was received at 8:13 P.M. and Emergency Medical Services (EMS) were on the scene and had patient contact at 8:19 P.M. The dispatch reason was Resident #70 was unconscious, fainting and the chief complaint was a change in mental status, the duration was not documented. The altered mental status was not normal for Resident #70 and he had aphasia (loss of ability to understand or express speech) which was not normal for him. Resident #70's blood pressure was 87/30. Resident #70 was found in bed conscious, but not responding to verbal prompts. Family stated Resident #70 had a cerebral hemorrhage one month ago and was at the facility for rehab. Resident #70 had a deterioration of cerebral function, and suddenly was unable to speak. Resident #70 was very lethargic, and only able to answer yes or no questions with head shakes and nods. Review of Resident #70's Emergency Department and hospital admission notes dated 02/10/23 included Resident #70 was admitted to the Emergency Department with a diagnosis of sepsis and acute kidney injury. The notes further stated due to high probability of imminent or life-threatening deterioration the patient required the highest level of preparedness and emergent intervention. Critical intervention was fluid resuscitation, and IV (intravenous) antibiotics (antibiotics). Resident #70 was hemodynamically unstable. Emergency Department notes stated Resident #70 presented for gradual confusion after recent discharge from the main hospital campus for ICH (intracerebral hemorrhage). Resident #70 appeared clinically dehydrated and was not receiving water via PEG (percutaneous endoscopic gastrostomy tube) which he was getting at the hospital. Resident #70 recently complained of increased thirst. Resident #70 was treated for aspiration pneumonia and urinary tract infection while in the hospital. Work up in the Emergency Department showed leukocytosis with left shift, acute kidney injury (AKI), lactate elevated at 3.2 (used to help diagnose sepsis). Resident #70 was administered antibiotics, but the source of infection was not identified. Resident #70's mental status improved with intravenous fluids (IVF). Resident #70 was temporarily hypotensive, but this responded to IVF and was felt to be secondary to dehydration. Interview on 09/06/23 at 4:54 P.M. of Family Member (FM) #308 revealed Resident #70 passed away on 08/10/23. FM #308 indicated Resident #70 had resided in the facility two and a half days, from 02/08/23 through 02/10/23. FM #308 stated Resident #70 was discharged on 02/10/23 when 911 was called. FM #308 stated the resident was alert and oriented on 02/08/23 when he was admitted to the facility, was learning to speak, and did not have an infection. FM #308 indicated Resident #70 was diagnosed with sepsis and acute kidney failure when he was taken to the Emergency Department on 02/10/23. FM #308 stated the physician at the hospital asked what the facility did to him and stated they had undone everything the hospital did for him before he was transferred to the facility. FM #308 revealed Resident #70 had a stroke about a month ago, was hospitalized and was admitted to the facility afterwards for rehabilitation and strengthening. FM #308 indicated she was at the facility from 6:00 A.M. until 9:00 P.M. on 02/09/23 and on 02/10/23 from 6:00 A.M. until he went to the hospital around 8:30 P.M. FM #308 stated she never left his room, and felt he was not taken care of and was not checked every two hours. FM #308 stated the nurses did not come in Resident #70's room unless she insisted. FM #308 stated on 02/10/23 Resident #70 was not looking well and was sweating. FM #308 indicated on 02/10/23 around 8:00 A.M. Physical Therapist/Therapy Manager (PT/TM) #213 and Occupational Therapist (OT) #309 came in the room and were unable to assist Resident #70 to sit up. FM #308 stated Resident #70 was sweating, not responding to her or her son and PT/TM #213 and OT #309 asked her if he sweated like that all the time. FM #308 stated OT #309 said he did not like the way Resident #70 looked and acted, and wanted to check his blood sugar. Resident #70 was sweating like crazy and a mechanical lift was used to transfer him to the wheelchair and he was taken to the Physical Therapy room. When Resident #70 came back to the room a short time later, FM #308 indicated OT #309 told her Resident #70's blood sugar was checked, it was fine, and he did not know what was wrong. FM #308 stated Speech Therapist (ST) #307 came in the room around 9:45 A.M., asked what was wrong with Resident #70, tried to work with him, was unable to get a response, and stated she could not work with him when he was like this. FM #308 stated by this time Resident #70 was shaking, his eyes were bulging, she tried to get staff to help her, and it took at least four hours for the staff to assist Resident #70 from the wheelchair into his bed. FM #308 stated she kept asking and yelling for staff and they did not come. FM #308 stated she later looked at Resident #70's medical record and the documentation did not reflect the issues Resident #70 was having. FM #308 stated his blood pressure, pulse and oxygen saturation were not checked when he was feeling badly. FM #308 stated she insisted Licensed Practical Nurse (LPN) #284 come in to check Resident #70 on 02/10/23 in the evening and insisted and yelled for him to call 911 to have an ambulance transport Resident #70 to the hospital. FM #308 stated Resident #70 never sweated profusely and she did not tell facility staff Resident #70 often sweated profusely. Interview on 09/07/23 at 10:38 A.M. of Speech Therapist (ST) #307 revealed Resident #70 was only in the facility a couple days, he was friendly and his family was very involved in his care. ST #307 stated on 02/10/23 while she worked with Resident #70 she noticed he was sweating, and she told the nurse he was sweating profusely. ST #307 stated she did not remember which nurse she told or if the nurse went in the room to evaluate Resident #70. ST #307 stated she wrote her notes at the end of the day, and her visit with Resident #70 was probably in the morning. ST #307 stated she could not remember if Resident #70 was hard to arouse, but recalled he was dripping with sweat. ST #307 stated she was sure she told the nurse because she was very concerned about Resident #70's condition. ST #307 stated on 02/09/23 Resident #70 was very interactive, but on 02/10/23 she just remembered him sweating. Interview on 09/07/23 at 12:00 P.M. of Physical Therapist/Therapy Manager (PT/TM) #213 revealed Resident #70 was a complex case, was a stroke victim and could not do much on the right side. PT/TM #213 stated on 02/09/23 Resident #70 was alert and a mechanical lift was used to transfer Resident #70 to a wheelchair. PT/TM #213 stated on 02/10/23 an unsuccessful attempt was tried to have Resident #70 stand. PT/TM #213 stated Resident #70 was very lethargic and hard to arouse, and unable to stand. PT/TM #213 stated the time of the therapy session was not documented but stated she probably saw him late morning or early afternoon. PT/TM #213 stated if a resident was not feeling well during therapy it was reported to nursing. PT/TM #213 indicated she did not remember if she talked to a nurse on 02/10/23. Interview on 09/07/23 at 6:19 P.M. of Licensed Practical Nurse (LPN) #284 revealed he worked night shift and took care of Resident #70 on 02/09/23 and 02/10/23. LPN #284 stated on 02/09/23 Resident #70 was more talkative. LPN #284 stated on 02/10/23 Resident #70's wife yelled at him, told him to come in the room to see Resident #70 and insisted an ambulance was called. LPN #284 stated Resident #70 did not look good, his blood pressure was low, he called NP #306 and Resident #70 was sent via a 911 call and EMS services to the Emergency Department. Interview on 09/11/23 at 8:17 A.M. of Nurse Practitioner (NP) #306 revealed Resident #70 was only in the facility a couple days and she did not remember many details about his stay. NP #306 stated she received a call late in the day around 8:00 P.M. on 02/10/23 when Resident #70 had altered mental status, low blood pressure and his family wanted him sent to the hospital. NP #306 stated the only time she was called by the facility nurses' was right before Resident #70 was transported via Emergency Medical Services (EMS) to the hospital. NP #306 stated she saw residents in the facility in the morning and was gone from the facility around 12:00 P.M. Interview on 09/11/23 at 10:23 A.M. of the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #219 revealed if a nurse checked a blood sugar it should be documented under weights and vital signs in the resident's electronic medical record. The DON and ADON #219 confirmed on 02/10/23 Resident #70 did not have a blood sugar documented in the morning and no blood sugars were documented until 8:07 P.M. Review of the facility policy titled Notification of Changes revised 04/15/21 included the purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician, and notified consistent with his or her authority the resident's representative when there was a change requiring notification. Circumstances requiring notification included a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This might include life-threatening conditions or clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00145033.