**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The admission MDS assessment dated [DATE] for Resident #35 reported he had a BIMS score of 13 indicating intact cognition. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, and toileting and extensive assistance of 1 staff for locomotion on and off the unit. The MDS indicated the resident had diagnoses of Guillain-Barre syndrome, hypertension, other fracture, and polyneuropathy. The initial care plan dated 6/17/22 identified the following focus areas for Resident #35: a. A need for assistance with grooming, personal hygiene, and other routine activities of daily living (ADL). The care plan instructed staff to encourage the resident to participate to the fullest extent possible with each interaction. b. A risk for falls due to altered extremity range of motion related to Guillain-Barre syndrome. The care plan instructed staff to encourage the use of his call light, provide a safe environment without clutter, ensure resident was wearing appropriate footwear, monitor for unsteady gait, and to have physical therapy (PT) and occupational therapy (OT) evaluate and treat as ordered. c. Chronic pain related to Guillain-Barre syndrome. The care plan instructed staff to anticipate the need for pain relief and respond immediately, evaluate the effectiveness of pain interventions, and to monitor, document and report to nurse as needed any signs or symptoms of non-verbal pain. A Patient Incident Reporting Form dated 7/8/22 at 6:57 AM and completed by Staff I, Physical Therapy Aide (PTA), reported Resident #35 was ambulating with Staff I, PTA holding onto his gait belt and following with a wheelchair. Resident #35's legs gave out and he fell forward with his legs folding up. The resident was held onto and lifted back into wheelchair without hitting the ground. Resident #35 reported his knees and ankles hurt and he was short of breath. The report indicated the physician was not notified. Physical Therapy Treatment Notes dated 7/8/22 stated Resident #35 ambulated 35 feet with a wheeled walker. The resident fell forward when both knees buckled and the PTA was able to lift the resident back into the wheelchair without him hitting the ground. Nursing was notified of the incident. Resident #35 expressed pain in bilateral lower extremities but did not rate pain just stated it hurt. The resident did not think he could do anymore with his lower extremities. An incident report was filled out. The EZ stand was used to transfer the resident from his wheelchair to his recliner with a posterior lean noted. PTA was unable to determine the resident's pain level at that time. Resident #35 did report a lot of pain in bilateral lower extremities after buckling during ambulation. Physical Therapy Treatment Notes dated 7/11/22 stated Resident #35 had reported he was supposed to get an x-ray on his lower extremity from the fall on 7/8/22 and staff noted swelling to right ankle/foot. Resident was apprehensive about doing anything with his lower extremities on this date. The notes stated pain noted with limited extension, flexion and walking. Rated pain at a 5 out of 10 and constant in his right knee and ankle. Progress notes in the electronic health records (Point Click Care) for Resident #35 failed to document any assessment of Resident #35 after the fall in PT on 7/8/22 and no documented assessments of any follow up of the fall on 7/9/22, 7/10/22 or 7/11/22. Progress notes in the electronic health records (Point Click Care) dated 7/11/22 at 3:26 PM for Resident #35 documented a phone order was received from Staff J, Advanced Registered Nurse Practitioner (ARNP) for 2 view x-ray of the right ankle and the resident was aware. X-ray results for the right ankle 2 views exam completed on 7/11/22 at 5:05 PM revealed there was an obliquely oriented nondisplaced fracture of the distal fibula. Presumably this was acute. There was some associated soft tissue swelling. The distal tibia was intact. There was some mild degenerative changes in the hindfoot and midfoot with osteopenia. No bone destruction. Atherosclerotic changes. Progress note dated 7/12/22 revealed resident was seen by Staff K, ARNP for a follow up on the fall and right ankle fracture. It stated Resident #35 was ambulating with PTA using a walker when his legs gave out beneath him. Afterwards he was complaining of pain and swelling in his right ankle where he had sustained a previous distal fibula fracture on 4/10/22. He reported his ankle did not hurt at rest. No swelling, erythema, warmth or displacement was noted of the right foot or ankle. Resident #35 had a repeat x-ray of his right ankle yesterday that reportedly was unchanged from his previous x-ray with no new fractures per the DON. The x-ray was not readily available for her review. Resident #35 stated the pain was tolerable at that time. Resident was encouraged to ambulate with a Cam boot on and elevate legs while seated. In an interview on 7/21/22 at 9:35 AM, Resident #35 reported he had a fall a couple of weeks ago while in PT. He reported he hurt his right ankle and that he had previously fractured that ankle. He stated he had instant pain in the ankle after the fall. He reported the staff got him up, put him in and chair and took him to his room. They did not complete an assessment or take his vital signs. He reportedly told staff his right ankle was hurting on 7/8/22, 7/9/22, and 7/10/22. He stated late on 7/10/22 a nurse put some ointment on the ankle for discomfort. He received an x-ray on 7/11/22 and was told he had fractured his right ankle and then was told he re-fractured the same area of his right ankle. He reported they had not told him anything more about the injury or how long he would need to wear the boot. In a phone interview on 8/3/22 at 5:31 PM, Staff K, ARNP reported she was covering for staff J, ARNP when she was asked to see Resident #35. It was reported to her the resident had experienced a fall and was complaining of pain and swelling to his right ankle. She stated the DON did confirm an x-ray was completed on 7/11/22 and that is did not show a new fracture. She stated she did not have access to the x-ray or the x-ray results at the time so took the DON's word for the x-ray results. She stated the assessment did not indicate any severe injury but was told there was no new fracture. She stated she did not follow up on the x-ray as she was only covering for Staff J, ARNP and assumed she would be following up if she thought it necessary. In an observation on 7/28/22 at 7:45 AM, Resident #35 was sitting in PT with weights on his ankles lifting his legs up and down. No Cam boot on right foot at the time but it was sitting by his wheelchair. Spoke with Staff L, OT regarding resident ambulating. She stated resident had not been ambulating until they receive more information from his upcoming orthopedic appointment to get more information about the recent x-ray that revealed a fracture of his right ankle. She stated ambulation had been put on hold since that time. In an interview on 7/27/22 at 2:40 PM, the Administrator reported the fall occurred while the resident was walking with Staff I, PTA and he had reported it to his supervisor, Staff M, Rehab Director. She reported Staff M, Rehab Director had not reported the fall for Resident #35 to nursing so nursing was not aware of the fall. In an interview on 7/27/22 at 2:40 PM, Staff N, Director of Regional Services reported Resident #35 was admitted with a previous right ankle fracture. She reported an x-ray dated 4/10/22 revealed resident had an acute oblique fracture of the right ankle. In an interview on 7/27/22 at 2:40 PM, Staff A, Regional Nurse Consultant, stated is was the expectation that an assessment was completed immediately after a fall and staff was to monitor the resident as needed. In a facility provided protocol titled Falls-Clinical Protocol revised March 2018, it stated the nurse is responsible to assess and document/report the following: a. vital signs b. recent injury, especially fracture or head injury c. musculoskeletal function d. change in cognition or level on consciousness e. neurological status f. pain g. frequency and number of falls since last physician visit h. precipitating factors i. all current medications j. all active diagnosis The protocol further stated the staff, with the physician's guidance, would follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma had been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. The on-site survey team provided the facility staff with the IJ Template on 8/9/22 at 11:02 AM. The facility staff removed the immedicacy on 8/10/22 by educating the nursing staff on the protocols for residents experiencing a change of condition. At the time of the survey, the scope and severity was at a J level, and has been changed to a D due to ensuring the facility staff follow their protocols for resident change of condition. Based on observations, clinical record review, Resident, family and staff interviews, the facility failed to complete timely assessments and interventions for 3 out of 3 (Residents #18, #35 and #328) residents reviewed, which resulted in immediate jeopardy for Resident #328. The facility failed to get emergency care in a timely manner for Resident #328. Staff were directed by the provider to contact family with an update in change of condition to see if the family wanted a higher level of care. There was a delay of approximately 3 hours in contacting the family followed by a delay of approximately 1 1/2 hours of contacting emergency services. Resident #328 was pronounced dead shortly after arriving to the Emergency Room. The facility failed to complete an assessment for over 4 hours for Resident #18 when he complained of chest pain and document the change of condition. The facility failed to provide an accurate assessment of an xray showing a fracture to a provider which resulted in a delay in interventions given to Resident #35. The facility reported a census of 85 residents. Findings included: 1. A Minimum Data Set (MDS) dated [DATE], documented Resident #328's diagnoses included diabetes, chronic obstructive pulmonary disease (COPD) and hemiplegia. This resident's Brief Interview for Mental Status documented a score of 8 out of 15, which indicated moderately impaired cognition. This resident required extensive assist of 2 staff for bed mobility and toileting. This resident required supervision of one for eating. A care plan for this resident initiated on 1/15/21 documented that Advanced Directives were to be followed per resident/family request. It directed staff to honor Resident #328's wishes as indicated on her CPR declarations page. The cancel date for this resident's care plan was 6/21/22. A Doctor's orders ordered by the Staff AA, ARNP (Nurse Practitioner) dated 6/20/22 at 9:00 A.M., directed that a CBC (complete blood count), CMP (complete metabolic profile) and CXR (chest x-ray) be done related to wheezing and inability to swallow. The order was discontinued on 6/21/22. A doctor's order dated 2/10/22, directed that this resident's code status was CPR ((Cardio Pulmonary Resuscitation) was to be performed if this resident's heart stopped and if she stopped breathing)). On 7/27/22 at 8:49 AM, Resident #328's daughter and #1 emergency contact, stated she did not understand why it would take so long to get her mother to the hospital on the day her mother passed away (6/20/22). The daughter stated a nurse had called her at 9:00 AM about her mother's condition. The facility reported that Resident #328 was not eating or drinking and her blood sugar was 39. The nurse reported they were going to get an x-ray and check this resident's blood sugar. Then at 1:05 PM, the nurse called again and stated her mother's glucose was 100 and her x-ray was fine but her mother was still not responding. The daughter stated she was told she needed to make a decision on whether she wanted her mother to be taken to the hospital. The daughter stated it was posed in a life or death way and she told the nurse to take mother to the hospital and she, the daughter, would meet/go to the hospital to meet her mom there. The daughter stated she was surprised that her mother's condition at that time had declined that much from the earlier phone call that day. The daughter said she literally called the hospital 3 times and her mother was not there yet. The daughter stated that by the time her mother got to the hospital, the doctor told the daughter that her mother's heart rate was really faint and then her mother went in to cardiac arrest and they couldn't revive her. She stated her time of death was 4:22 PM. The daughter said she received a text from the hospital which read check in was 4:27 PM. The daughter said she didn't understand why it took so long to get her mother to the hospital after the daughter told the nurse at the facility to send her mother to the hospital. A screen shot provided by the daughter of a call log from her phone showed on 6/20/22 there was an incoming call at 8:53 AM that lasted 1 minute and 43 seconds. The next call on the screen shot was an incoming call at 1:05 PM and lasted 1 minute and 45 seconds. A text message dated 6/20/22 at 4:27 PM and provided by the daughter, read (Resident's name) welcome to (Hospital's name). A State Of Iowa Death Certificate documented the actual time of death was on 6/20/22 at 4:24 PM. An email sent by a staff member of the Sheriff's Office and dated 8/8/22 at 10:53 AM, read that according to their Communications Division- the event for the first Fire Department was created at 2:40 PM, and the event for the second fire department was created at 2:41 PM. These events referenced when the facility contacted the EMS for transfer from the facility to the hospital of Resident #328. Progress Notes for Resident #328 documented the following: -On 6/19/2022 at 3:08 PM, Nurses Note- this resident had an emesis (vomited) after the morning meal today and numerous loose stools as well. Vital Signs were stable and they did a covid test and it was negative as well. Temperature 97.9. -On 6/19/2022 at 9:06 PM, Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vital Signs: T(temperature) 97.7 - 6/12/2022 at 12:21PM Route: Forehead (non-contact) BP (blood pressure) 124/72 - 6/1/2022 at 6:08 PM Position: Lying l(left)/arm P (pulse) 76 - 6/1/2022 6:08 PM Pulse Type: Regular R (Respirations) 22.0 - 6/12/2022 at 12:21 PM O2 (oxygen saturation) 97.0 % - 6/12/2022 at 12:21 PM Method: Room Air Pnl (pain level) 0 - 6/19/2022 12:02 AM Pain scale: Numerical No further N/V or loose stools. -On 6/20/2022 at 3:51 AM, Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vital Signs T 98.2 - 6/20/2022 3:50 AM Route: Tympanic (ear) BP 120/64 - 6/20/2022 at 3:50 AM Position: Lying l/arm P 78 - 6/20/2022 at 3:50 AM Pulse Type: Regular R 16. -6/20/2022 at 3:50 AM O2 95.0 % - 6/20/2022 at 3:50 AM Method: Room Air Pnl 0 - 6/20/2022 at 3:50 AM Pain scale: Numerical Resident alert and oriented by name and place only sleeping during this shift no c/o nausea no emesis noted, no loose stools denies any GI distress or pain. -On 6/20/2022 at 8:34 AM CMA (Certified Medication Aide) came to this nurse (Staff C, Licensed Practical Nurse (LPN)) and stated residents blood sugar was only 39. This nurse went to resident room and noted resident to be in bed awake and responsive. Lethargic but responsive. Staff assisting with attempting to get blood sugar above 39 with drinking OJ that had sugar in it but resident would cough on it and was not swallowing well at all. So thickened liquids was given with sugar added. Resident noted as well to have audible expiratory wheezing only, no inspiratory wheezing. Nurse notified ARNP (Staff AA) received orders to do a 2 view CXR and lab work as well give glucagon tablets following the label on the bottle per distributors directions. Notified daughter of concerns and condition, told would keep up to date. -On 6/20/2022 at 8:46, eINTERACT SBAR Summary for Providers note, Situation: The Change In Condition/s reported on this Evaluation are/were: Abnormal At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 110/59 - 6/20/2022 at 8:43 AM Position: Lying r/arm Pulse: P 112 - 6/20/2022 at 8:43 AM Pulse Type: Irregular - new onset - R 22.0 - 6/20/2022 at 8:43 AM Temp: T 98.2 - 6/20/2022 08:43 Route: Tympanic Weight: (W) 144.6 lb - 6/8/2022 at 7:54 PM Scale: Mechanical Lift Pulse Oximetry: O2 89.0 % -6/20/2022 at 8:43 AM Method: Room Air Blood Glucose: BS (blood sugar) 39.0 6/20/2022 at 8:43 AM Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON-DOMINANT SIDE DYSPHAGIA, OROPHARYNGEAL PHASE Relevant medical history is: Diabetes Code Status: CPR Resident/Patient is on: Hypoglycemic medication(s)/Insulin Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: No changes observed. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: CXR CBC CMP glucose tablets per directions to bring blood sugar up above 80 B. New Testing Orders: Blood Tests X-ray C. New Intervention Orders: Other Labs CXR -On 6/20/2022 at 9:03 AM, Nurses Note Residents blood sugar up to 78 but condition still the same eyes rolled back a lot of stimulation to get resident to swallow any type of liquids would respond to verbal ques still needing O2 but pulse tacky at 120 and this was apically (listened to the heart with a stethoscope) done. Resident's respirations were irregular and mouth breathing as well. This nurse attempted x 2 to obtain the lab work and was unsuccessful with the lab draws. Resident still stable with blood glucose but not presenting well. -On 6/20/2022 at 10:43 AM, Nurses Note: CXR obtained and ARNP in house to review with no new orders ARNP went down to look at resident and is concerned with resident's presentation wants this nurse to call and speak to family about how far they want to pursue treatment. -On 6/20/2022 at 2:44 PM, Nurses Note: Called daughter to give update on condition of mother and daughter states that she would like mom to be sent out to emergency room to be evaluated and treated. Daughter insist that mom be sent out so order obtained to send mom out to the hospital per ARNP. Called 911 -On 6/20/2022 at 3:00 PM, Nurses Note: EMT (Emergency Medical Technicians) here to pick up resident report given resident very lethargic now and not responding well at all. EMT's perform sternum rub to wake resident up and get a response from her and had no luck resident eyes were rolled back into head and resident very flaccid in extremities. -On 6/20/22 at 5:00 PM, Notified that resident passed way at the hospital. On 7/27/22 at 12:23 PM, Staff AA, ARNP, stated she no longer worked at this facility. She stated the facility should have access to her notes. She stated she had ordered lab and a chest x-ray for this resident the morning of this resident's passing. She stated she doesn't remember exactly what the x-ray showed, and did not think they had obtained the lab work by the time she had went in and assessed Resident #328. After assessing this resident, the ARNP remembered telling the nurse to call family to get direction regarding whether or not they wanted this resident sent to the hospital, because if the family wanted this resident sent out she needed to be sent out. This ARNP stated that around noon, she told the nurse to transfer the resident out now, to get her to the hospital now. She stated she remembered that this resident did not go to the hospital right away. The ARNP stated there was no way to say whether or not the same outcome would have occurred if the facility would have transferred this resident out right away, however this ARNP remembered that after hearing the family wanted this resident transferred out, this ARNP felt this resident needed to be transferred out right away. The ARNP acknowledged that there was a lag of time between when the facility knew that the family wanted this resident transferred out to when they actually transferred the resident out On 7/27/22 at 2:45 PM, Staff C, Licensed Practical Nurse (LPN), stated she was trying to remember what the situation was with Resident #328. She knew Resident #328 had nausea and vomiting (N/V) and wasn't feeling the best. Resident #328's blood sugars were really weird, we were trying to give her OJ and milk trying to bring the blood sugar back up. The ARNP was here physically and said send her out. Staff C stated she was the covering nurse that day but didn't remember exactly what timing was and then she looked at her progress notes. Staff C stated she did not remember a delay in sending this resident out. Staff C stated she would have to find her notebook, to find out what she was doing that day. Staff C stated she would find her notebook to check into things. She stated she could almost guarantee there was something else going on that day because she would not have waited that long to send Resident #328 out. She stated she was covering 2 halls that day- there was probably only 2 nurses, with herself on halls 2 and 1 and the other nurse on halls 3 and 4. A CMA would have covered 1 and 4. She stated she would look into it further, look at her notebook and find out what else was going on. She said a CMA would have been on halls 1 and 4, so she would have been responsible for meds, treatments and insulins on hall 2 and insulins and treatments on hall 1. On 7/28/22 at 10:27 AM, Staff C stated she checked her notebook and what happened was the nurse practitioner, Staff AA, told her to call the family first. Staff C stated she kept trying to call the family. Staff C stated by the time she got the return call from the family it was 2:00 PM. Staff C stated she called the EMS (Emergency Medical Services) right away. Staff C stated the EMS sat there forever in the facility parking lot. She stated by the time they pulled away it was almost 3 PM. Staff C stated she did not know what the EMS was doing when they got Resident #328 in the ambulance. When told the daughter reported that Staff C had called her at 1 PM, Staff C stated yeah, that could have been. Staff C had no further information. On 8/9/22 at 2:02 PM, Staff AA, ARNP, stated she did not remember the exact time she gave the order to send out but remembered that Staff C was on the phone with the daughter at the time she gave the order. Staff AA stated she was blunt in telling Staff C that Resident #328 needed to be sent out now. Staff AA stated her order correlated directly to the time Staff C was on the phone with the daughter, and if the daughter has 1:05 p.m. screen shot, then it was 1:06 p.m. when this ARNP gave the order to transfer Resident #328 out. This ARNP stated she was shocked that the family hadn't already been called and she stood there as Staff C made the call to the family. Staff AA stated she knew she was standing there when Staff C made that call and Staff AA knew she had requested that the family be called at least twice that day, there may have even been a third time that she asked Staff C to call the family, but Staff AA couldn't say that for sure. Staff AA told Staff C when Staff C called the daughter that Staff AA was going to stand there while Staff C made the call because Staff AA wanted to act right away if the daughter wanted her mom to remain a full code and wanted her mom to be sent out. Staff AA also wanted to be there to give education to the daughter regarding palliative care if the daughter had questions about change of code status. Resident #328's daughter did not want code status changed and wanted her mother sent out. Staff AA gave the order right then to get this resident transferred up to the hospital. Staff AA stated she made sure she was present for that, so there was no delay. This ARNP stated she couldn't speak to why there was a delay in Staff C calling the ambulance. Staff AA did not know if there was any other crises going on in the building on that day. Staff AA stated she understand they had a lot of residents to take care of, but Staff AA felt this resident was definitely a priority. Staff AA stated she did see most of the population at the facility and this resident was her only hot patient there that day. Staff AA felt like a verbal order was given that day as it was clear to send this resident out. She stated that normally with orders, she would write them because there can be some question on interpretation such as dosage, or frequency of a medication. Staff AA stated this order was very clear. This whole situation was a little shocking to her. Staff AA stated she wouldn't say it was blatant neglect but it could be looked at as situational neglect. The ARNP stated she had worked with Staff C quite a while and this was unusual for Staff C to not be right on top of this. On 8/10/22 at 10:24 AM, the Director of Nursing (DON), stated that she was on 400 and 300 halls and Staff C was on 200 and 100 halls. The DON stated she had a CMA but didn't' remember which CMA was on Staff C's side. The DON remembered a resident's daughter came out told the DON that her mom was somewhat non-responsive. The DON went and spoke to Staff AA. Staff AA ordered to send her (a different resident, not Resident #328) out. The DON stated the resident on her side was then transferred to the hospital for further evaluation and treatment. The DON stated this was her first day and the DON had chosen to be on the floor, just to see how the flow went. The DON stated nothing was brought to her attention that day from the other side and she wasn't asked to help on the other side. The DON stated that in fact, she had went over and talked to Staff C regarding what forms the DON needed to send somebody to the hospital. The DON stated Staff C pointed out the forms the DON would need on the computer the e-interact form and the phone numbers the DON would need. The DON stated she had no idea there was anything going on over on Staff C's side, nor was the DON asked to help over there. On 8/10/22 at 10:56 AM, Staff BB, Certified Medication Aide (CMA), stated that when Resident #328 was very sick and had a low BP. Staff BB remembered that day (6/20/22) because Staff BB did not get her morning medications passed until late. Staff BB stated it was the same morning the doctor ordered a chest x-ray. Staff BB stated she was not usually on the 200 hall. Staff BB stated she had been at the facility for a while and knew everyone but she wasn't as fast on 200 hall as she was on the 300 hall. Staff BB stated she knew Resident #328. Staff BB had checked Resident #328's blood sugar and it was very low and Staff BB stated she was diabetic as well. Staff BB stated the aides had told her that Resident #328 wasn't acting right. She stated they started giving this resident thickened orange juice. Staff BB let the nurse (Staff C) know, and Staff C went and called the doctor. Staff BB wanted to say they checked Resident #328's blood sugar 6 or 7 times that day, so Staff BB was busy getting those blood sugars. The nurse had been in quite a few times to get updates. Staff BB stated the nurse was covering Staff BB's side, and she was on 100 hall that had like 6 or 7 residents on that hall. Staff BB did not remember if anyone over on 100 hall was sick. Staff BB stated she was very, very, busy with Resident #328. Staff BB stated that she was diabetic herself, so Staff BB spent a lot of time with Resident #328 trying to get her blood sugar up. Staff BB stated they would get the blood sugar up and it'd go back down again. Staff BB stated that she was very ocd-ish and remembered it all very well because she was falling behind with passing medications (meds) probably by an hour or two. Staff BB stated that she was pretty sure her shift was over at 2:00 PM. Staff BB had stopped to assist with the x-rays around lunch time. Staff BB stated she knew she was in the middle of passing meds. The x-rays were taken before Staff BB left but now long before she left. Usually Resident #328 was very quiet. Staff BB stated she would describe Resident #328 as more lethargic. It took longer with thickened liquids to raise her blood sugar. Staff BB stated that normally Resident #328 could talk but wouldn't talk a lot. That morning she wasn't unresponsive. Staff BB stated she knew finally that the doctor had okayed an x-ray and the people (to get the x-ray) got there and then her shift was over. Staff BB stated she had spent a lot of time in that room. When Staff BB was told the orders for x-ray and labwork were given earlier in the day, Staff BB stated that could be that the orders for xray and lab were given around 8:30 AM, because she knew Staff CC went in to get her labs at that time. Staff BB was fairly sure x-ray came in the afternoon. Staff BB stated that around lunch time she ate pudding and applesauce probably about a quarter of it. Staff BB had to prompt Resident #328 and remind her to swallow and make sure she wasn't pocketing her food. Staff BB stated that when she came in the morning, the aides were going to get Resident #328 up and when they laid her down she was already dressed and Resident #328 sounded like she needed to cough. Staff BB stated that Resident #328 was with it enough where she was following directions. Staff BB stated Resident #328 was very lethargic and was slow to respond. Staff BB stated she would definitely say Resident #328 wasn't her normal self. Staff BB didn't remember a conversation with Staff C regarding calling this residents family about a transfer to the hospital. Staff BB stated that Staff C relaying updates with the nurse practitioner to Staff BB. Staff BB said that Staff C told Staff BB about rechecking blood sugars and about the x-ray. They (the aides) said Resident #328 hadn't been feeling well for a couple days and Staff BB asked why and the aide said Resident #328 might have had a cold or something. Staff BB asked Staff CC, Temporary Nurse Aide (TNA), to keep an eye on Resident #328 when I had to go do other things because Resident #328 was crashing. Staff BB stated that she didn't think in all the years she'd been a med aide, she'd had to work that hard. Staff BB stated when it is acute blood sugars like that, the nurse comes in. Staff BB stated Staff C would ask Staff BB to go check Resident #328's blood sugars again. Staff BB stated Staff C knew that Staff BB was behind with the meds. Staff BB stated she knew that Staff C was really busy, but wasn't sure what was going on. Staff BB stated that Staff C had said even though she only had a few people to take care of (that weren't the regular residents on 100 hall), she was frustrated and said she was behind too. Staff BB did not know why. Staff BB thought maybe it was because of the x-ray and they weren't coming. Staff BB repeated she was not sure why Staff C was busy. Staff BB did not know if anyone was sick over on the 100 hall. Staff BB stated that Staff CC was one of the aides and a girl from agency who had been there a couple of times was the other aide working with Staff BB. Staff BB knew that Staff CC was there because she is one that Staff BB asked to keep a close eye on Resident #328 because Resident #328 was crashing and she had to go pass meds to other residents. On 8/10/22 at 12:27 PM, Staff CC, TNA, stated that morning (6/20/22), Resident #328 looked very sick. Staff CC stated they kept Resident #328[TRUNCATED]