**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure allegations of neglect were thoroughly investigated to prevent further elopement and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for neglect. The facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #1 eloped from the facility for an unknown amount of time and was found down the street approximately 150 yards from the facility by law enforcement. She had crossed a street and was in a 30 mile per hour area. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 11/4/23 at 7:25 p.m. While the IJ was removed on 11/6/23 at 11:20 a.m., the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect residents by placing the residents at risk for harm. Findings include: Record review of a Face Sheet dated 11/4/23 for Resident #1 indicated she admitted to the facility on [DATE] and she is [AGE] years old with diagnoses of chronic obstructive pulmonary disease, cognitive communication deficit, type II diabetes mellitus, unspecified dementia, unspecified psychosis, abnormalities of gait and mobility, and lack of coordination. Record review of a care plan dated 10/4/2023 for Resident #1 indicated she is an elopement risk/wander and needed to be monitored frequently by staff. A Quarterly MDS dated [DATE] indicated Resident #1 has impairment in thinking with a BIMS score of 3. She requires supervision when walking in room and corridor and with locomotion on and off the unit. Record review of Incident Log dated 11/4/23 indicated Resident #1 had an elopement on 10/8/23 at 11:00 a.m. Record review of the In-Service book indicated an Elopement In-service was initiated on 10-18-23. There were a total of 23 names listed on the sign in sheet for this training. Record review of a nurse progress note dated 10/8/23 by nurse A indicated Resident #1 was found outside of the facility and was brought back inside. During an interview on 11/4/23 at 12:53 p.m., CNA B said she's been employed at the facility for 5 months. She said on 10/8/23 she was one of the CNAs caring for Resident #1. She said she last remember seeing Resident #1 at breakfast. She said she began looking for Resident #1 around 9:30 a.m. She said she had last saw Resident #1 at 9:00 a.m. but had not seen her again. She said she searched halls and rooms but was unable to locate her. She said she notified LVN A she was unable to locate Resident #1 and they both searched for Resident #1. She said after being unable to locate Resident #1 in the facility she went outside and was looking up and down the street. She said she located Resident #1 approximately 200 yards down the street talking to law enforcement. She said when she got to Resident #1, she appeared confused and upset. She said she attempted to get Resident #1 to walk back to the facility with her, but Resident #1 refused. She said a few minutes later LVN A arrived on the scene and attempted to get Resident # 1 to return to the facility. She said Resident #1 said she wanted the police to take her back to the facility. She said law enforcement agreed to follow Resident #1 to the facility. She said LVN A persuaded Resident #1 to get in LVN A car and she transported Resident #1 back to the facility with the police closely following. She said she did not tell the administrator about the incident because she heard LVN A talking to the administrator about the incident. She denied the DON or administrator asked her about the situation. During an interview on 11/4/23 at 12:59 p.m., CNA C said she's been employed at the facility for 2 months. She said she was at work on the day of the elopement of Resident #1. She said she helped search for her in the facility, but she denied going outside to look for Resident #1. She denied anyone questioned her regarding the elopement of Resident #1. She also denied receiving training/in-service on abuse/neglect or elopement. During an interview on 11/4/23 at 1:10 pm., with Corporate Nurse said she's worked in the facility for the past 3 weeks. She said she was aware of the elopement of Resident #1. She said the DON was terminated and she came in to assist the facility. She said she was not sure if an investigation was completed prior to her arrival at the facility nor was she aware if the incident had been called in to the state agency. During an interview on 11/4/23 at 2:20 p.m., the Administrator identified himself as the Administrator and acknowledged he is the abuse coordinator. He said he has worked at the facility for the past 4 months. He said he was made aware of the elopement of Resident #1 on the day of the elopement. The administrator said he did not report the incident to the state agency because he was told Resident #1 was let out of the facility by another resident's family but was immediately re-directed back in the facility. He denied investigating the incident. He said he instructed the DON to investigate. He denied having record of the DON's investigation. The Administrator said the DON did not investigate and was terminated for not being unable to fulfill her job duties. During an interview on 11/4/23 at 3:38 p.m., LVN A said she's worked at the facility 4 years. She said she works the 6 AM - 6 PM and she works every other weekend. She said she was Resident #1 nurse on the day of the incident. She said Resident #1 has a habit of wandering around the facility. She said she was notified by CNA B that Resident #1 was missing but didn't remember the time of day she was notified. She said both she and CNA B searched for Resident #1 inside the facility. She said she notified the Administrator of the resident missing after being unable to locate her inside the facility. She said after searching inside they went outside and began searching. She said she got in her car and began driving down the road. She said was driving up the street when she received a call from the HR Manager. She said the HR Manager told her Resident #1 had been located, and she was the opposite direction in which she was traveling. She said she turned around and headed to where Resident # 1 was located. She said when she arrived Resident #1 was there with CNA B and law enforcement. She said Resident #1 appeared upset and confused when she spoke to her. She said she tried to calm Resident #1 down and coax her to get in the car but Resident #1 refused. She said Resident #1 said she wanted the police to take her back to the facility. LVN A said law enforcement told Resident #1 they would follow her back to the facility in their car, if she rode with LVN A. She said Resident #1 agreed and got LVN A car. She said she called the Administrator and informed him Resident #1 had been found. She said after they returned to the facility. She did a head-to-toe assessment on Resident #1 and no injuries were found. She said called Resident #1 daughter and nurse practitioner and notified them of the incident. She said she notified the DON and was told to place Resident #1 on one-on-one and to not allow Resident #1 out of her site. She said the DON told her to only document, Resident #1 got out of the facility and was found. LVN A said she only documented what she was told in the chart. LVN A said she was not questioned on the incident by the administrator or the DON. She also denied receiving in-service/training on elopement or abuse/neglect after the incident. During an interview on 11/6/23 at 10:33 a.m., CNA D said she was here on the day of the elopement, but she was working on the other side of the facility. She denied talking to the DON or the administrator about the incident. She also denied the DON or administrator spoke to her about the incident. Record Review of the facility's abuse/neglect policy dated December 2009 stated the following; Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management; A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. The Administrator will provide a written report of the results of all abuse investigations and appropriate actions taken to the state agency and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. On 11/4/23 at 7:25 p.m., the Administrator was informed an Immediate Jeopardy (IJ) was identified due to the above failure. The IJ template was provided to the Administrator and a Plan of Removal (POR) was requested. The plan of removal indicated the following: Residents residing in the facility have the potential to be affected by the failure to investigate allegations of neglect. Resident #1 was placed on one-on-one supervision. Resident will be removed from one-on-one and placed on Q15 checks after evaluation from NP. Resident will be removed from Q15 with no episode of elopement for 72 hours. MD was notified, resident was treated for UTI 10/9 to help with confusion. Residents care plan updated to address elopement risk. Speaking with Physician on 11/6 monthly CBC ordered to monitor white blood cell count to help identify and treat potential confusion. The facility initiated an investigation to identify the cause and implement interventions. All residents residing in the facility have the potential to be affected by this deficiency. An audit was completed to ensure other residents with the potential for elopement were given the same interventions. One other resident was identified for elopement risk were place on 15min q checks. 2. The following actions were initiated immediately on 11/4/23. A. On 11/4/23 an in-service was initiated with the Administrator/DON by the RVP on the need to report and thoroughly investigate allegations of abuse and neglect to include allegations of elopement to ensure proper interventions are placed for residents' safety. The incident will be reported to HHSC. B. On 11/4/23 an in-service was initiated by the Administrator with All facility staff on the need to report allegations of abuse and neglect including allegations of elopement to the abuse coordinator to ensure proper interventions are placed for residents' safety. Staff will not be allowed to work on the floor without receiving the in-service completion date for training will be 11.5.23 C. An audit was completed on 11/4/23 by the Administrator of the 72-hour summary Report and grievances for all residents residing in the facility for any reported neglect allegations, none were identified. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/4/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was accepted on 11/6/23 at 11:20 a.m. On 11/7/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations were performed on 11/7/23 2:10 p.m. to 6:18 p.m. Resident #1 was observed with staff always with her during the visit. Interviews with 3 Licensed Nurses (on all shifts 6 a.m.- 6 p.m., 6 p.m.-6 a.m.), 1 RN (6 a.m.- 2 p.m.,10 p.m.- 6 a.m., 6 p.m.- 6 a.m.) and 6 CNAs ( 2 p.m.-10- p.m., PRN) were performed on 11/6/23. All staff were able to correctly identify the abuse coordinator. They stated they had received in-services on abuse/neglect, elopement, and who and when to report abuse/neglect allegations. The staff stated they learned to report missing residents over the intercom system immediately, and to notify the charge nurse and abuse coordinator/administrator. During an interview on 11/15/23 at 11:44 a.m., the Administrator said staff were in-serviced on abuse/neglect, and elopement. The Administrator said staff not in-serviced will be in-serviced prior to their shift. The Administrator said he and the cooperate nurse are monitoring the staffing schedule to ensure all staff on the schedule have been trained or still need to be. The Administrator said the employee files were reviewed and updated with the required trainings and files will be audited bi-weekly for 1 month, monthly for 3 months and then quarterly to ensure all employees have completed the required trainings. The Administrator said employee file audits will be discussed monthly during the monthly Quality Assurance meeting or as needed. The Administrator said staff will be in-serviced upon hire and annually. He said Resident #1 was being moved on 11/17/23 to a different facility where her needs could be met. The Administrator said the incident was called into the state agency and he will call in all any further reports of abuse/neglect to the state agency in the allotted time as required by the state. On 11/7/23 at 5:36 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Threat and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to provide adequate supervision to prevent elopement for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: Resident #1 eloped from the facility for an unknown amount of time and was found approximately 150 yards away from the facility by a neighboring facility and law enforcement. She had crossed a street and was in a 30 mile per hour area. An Immediate Jeopardy (IJ) was identified on 11/4/23 at 7:25 p.m. While the IJ was removed on 11/6/23 at 11:20 a.m., the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect residents by placing the residents at risk for harm. Finding include: Record review of a Face Sheet dated 11/4/23 for Resident #1 indicated she admitted to the facility on [DATE] and she was [AGE] years old with diagnoses of chronic obstructive pulmonary disease, cognitive communication deficit, type II diabetes mellitus, unspecified dementia, unspecified psychosis, abnormalities of gait and mobility, and lack of coordination. A Quarterly MDS dated [DATE] indicated Resident #1 had impairment thinking with a BIMS score of 3. She required supervision when walking in room and corridor and with locomotion on and off the unit. Record review of a care plan dated 10/4/2023 for Resident #1 indicated he was an elopement risk/wander and needed to be monitored frequently by staff. Record review of a nurse progress note dated 10/8/23 by nurse A indicated Resident #1 was found outside of the facility and was brought back inside. Record review of Incident Log dated 11/4/23 indicated Resident #1 had an elopement on 10/8/23 at 11:00 a.m. Record review of the In-Service book indicated an Elopement In-service was initiated on 10-18-23. During an observation on 11/4/23 at 11:47 a.m. with Resident #1 was found seated in the activities room with another resident. The assistant activities director was seated in her office with the door open. During an interview on 11/4/23 at 12:53 p.m., CNA B said she's been employed at the facility for 5 months. She said on 10/8/23 she began looking for Resident #1 around 9:30 a.m. She said she had last saw Resident #1 at 9:00 a.m. but had not seen her again. She said she searched halls and rooms but was unable to locate her. She said she notified LVN A, and they both searched for Resident #1. She said after being unable to locate Resident #1 in the facility she went outside and was looking up and down the street. She said she located Resident #1 approximately 200 yards down the street talking to law enforcement. She said she got to Resident #1 she appeared confused and upset. She said she attempted to get Resident #1 to walk back to the facility with her, but Resident #1 refused. She said a few minutes later LVN A arrived on the scene and attempted to get Resident # 1 to return to the facility. She said Resident #1 said she wanted the police to take her back to the facility. She said law enforcement agreed to follow Resident #1 to the facility. She said LVN A persuaded Resident #1 to get in LVN A car and she transported Resident #1 back to the facility with the police closely following. During an interview on 11/4/23 at 1:48 p.m., Human Resource Manager said she worked at the facility 9 years. She said she was working on the day of Resident #1s elopement. She said LVN A was looking for Resident #1 when she received a call from the facility across the street. She said the person on the phone told her a Resident #1 was located down the street and they believed she was from this facility. She said she notified LVN A. She said when Resident #1 was brought back to the facility she appeared upset and confused. During an interview on 11/4/23 at 2:20 p.m., the Administrator identified himself as the Administrator and acknowledged he was the abuse coordinator. He said he has worked at the facility for the past 4 months. He said he was made aware of the elopement of Resident #1 on the day of the elopement. He said LVN A called him and told him Resident #1 was missing but was found shortly after staff began looking for her. He said he called and notified the DON of the elopement. He denied coming to the facility on the day of the incident. He said he was notified of the elopement after the resident had returned to the facility. The administrator said he did not report the incident because he was told Resident #1 was let out of the facility by another resident's family but was immediately re-directed back in the facility. He said he was not aware of the length of time Resident #1 was outside the facility. He said he was made aware of law enforcement involvement until 10/19/23. He said the DON initiated 15-minute checks on Resident #1. He denied investigating the incident. He said he instructed the DON to investigate. During an interview on 11/4/23 at 3:38 p.m., LVN A said she's worked at the facility 4 years. She said she worked the 6 AM - 6 PM and she works every other weekend. She said she was Resident #1s nurse. She said Resident #1 has a habit of wandering around the facility. She said she was notified by CNA B that Resident #1 was missing but did not remember the time of day she was notified. She said both she and CNA B searched for Resident #1 inside the facility. She said she notified the Administrator of the resident missing after being unable to locate her inside the facility. She said after searching inside they went outside and began searching. She said she got in her car and began driving down the road. She said was driving up the street when she received a call from the HR Manager. She said the HR Manager told her Resident #1 had been located in the opposite direction in which she was traveling. She said she turned around and headed to where Resident # 1 was located. She said when she arrived Resident #1 was there with CNA B and law enforcement. She said Resident #1 appeared upset and confused when she spoke to her. She said she tried to calm Resident #1 down and coax her to get in the car but Resident #1 refused. She said Resident #1 said she wanted the police to take her back to the facility. LVN A said law enforcement told Resident #1 they would follow her back to the facility in their car, if she rode with LVN A. She said Resident #1 agreed and got LVN A car. She said she called the Administrator and informed him Resident #1 had been found. She said after they returned to the facility. She did a head-to-toe assessment on Resident #1 and no injuries were found. She said called Resident #1 daughter and nurse practitioner and notified them of the incident. She said she notified the DON and was told to place Resident #1 on one-on-one and to not allow Resident #1 out of her site. She said the DON told her to only document, Resident #1 got out of the facility and was found. LVN A said she only documented what she was told in the chart. During an interview on 11/4/23 at 3:55 p.m., the Administrator said the facility set up 15- minute checks on Resident #1 for 3 days following the incident. He said the Nurse Practitioner ordered a urinalysis completed on Resident #1. He said Resident #1 was found to have a urinary tract infection and she was treated per the nurse practitioner's orders . The administrator said for safety precautions, a sign was placed on the door stating, Do not allow anyone outside of the facility except yourself. He said the DON was terminated by the facility on 10/16/23 for not being able to fulfill her job duties. Record Review of the facility's abuse/neglect policy dated December 2009 stated the following; Policy Statement: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management; Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On 11/4/23 at 7:25 p.m., the Administrator was informed an Immediate Jeopardy (IJ) was identified due to the above failure. The IJ template was provided to the Administrator and a Plan of Removal (POR) was requested. The plan of removal indicated the following: Residents residing in the facility have the potential to be affected by the failure to provide adequate supervision to prevent elopement. Resident #1 was placed on one-on-one supervision. Resident will be removed from one-on-one and placed on Q15 checks after evaluation from NP. MD was notified, resident was treated for UTI 10/9 to help with confusion. Residents care plan updated to address elopement risk. Speaking with Physician on 11/6 monthly CBC ordered to monitor white blood cell count to help identify and treat potential confusion. The facility initiated an investigation to identify the cause and implement interventions. All residents residing in the facility have the potential to be affected by this deficiency. An audit was completed to ensure other residents with the potential for elopement were given the same interventions. One other resident was identified for elopement risk and placed on Q15 checks, based on evaluation Q15 checks are adequate to meet the patient's needs. 1. The following actions were initiated immediately on 11/4/23. a. One other resident identified for elopement risk, placed on Q15 min checks to be conducted by the nurses. The checks will be documented on the Q 15 form. Nurses in-serviced on _11/15 _ by the DON. The NP will evaluate the patient 11/7 to /determine if q15 is to be removed. b. On 11/4/23 an in-service was initiated with the Director of Nursing and Administrator by the Regional Nurse on the need to identify residents who are at risk for harm because of unsafe wandering to ensure adequate supervision is provided. If a resident is identified at risk for unsafe wandering a staff member will be placed with resident, physician will be notified, and DON and administrator will be notified to adjust staffing schedules. c. On 11/4/23 an in-service was initiated for the licensed nursing staff by the DON/ Designee on the need to identify residents who are at risk for harm because of unsafe wandering to ensure adequate supervision is implemented. All untrained Nursing staff (Nurses, CNA, CMA) will not be allowed to work on the floor without receiving the in-service. This will be completed by 11/5/23 midnight. d. An audit was completed on 11/4/23 on wander-risk residents to determine adequate supervision. One other resident was identified at risk and placed on Q15 minute checks residents care plan updated for elopement risk. MD ordered UA pending results. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/4/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was accepted on 11/6/23 at 11:20 a.m. On 11/7/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations were performed on 11/7/23 2:10 p.m. to 6:18 p.m. Resident #1 was observed with staff always with her during the visit. Interviews with 3 Licensed Nurses (on all shifts 6 a.m.- 6 p.m., 6 p.m.-6 a.m.), 1 RN (6 a.m.- 2 p.m.,10 p.m.- 6 a.m., 6 p.m.- 6 a.m.) and 6 CNAs ( 2 p.m.-10- p.m., PRN) were performed on 11/6/23. All staff were able to correctly identify the abuse coordinator. They stated they had received in-services on abuse/neglect, elopement, and who and when to report abuse/neglect allegations. The staff stated they learned to report missing residents over the intercom system immediately, and to notify the charge nurse and abuse coordinator/administrator. During an interview on 11/15/23 at 11:44 a.m., the Administrator said staff were in-serviced on abuse/neglect, and elopement. The Administrator said staff not in-serviced will be in-serviced prior to their shift. The Administrator said he and the cooperate nurse are monitoring the staffing schedule to ensure all staff on the schedule have been trained or still need to be. The Administrator said the employee files were reviewed and updated with the required trainings and files will be audited bi-weekly for 1 month, monthly for 3 months and then quarterly to ensure all employees have completed the required trainings. The Administrator said employee file audits will be discussed monthly during the monthly Quality Assurance meeting or as needed. The Administrator said staff will be in-serviced upon hire and annually. He said Resident #1 is being moved on 11/17/23 to a different facility where her needs could be met. On 11/7/23 at 5:36 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not an Immediate Threat and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately consult with the resident physician when there was a significant change in the resident physical condition for 1 of 6 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced nausea and vomiting for 3 days after receiving new medications. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. On arrival to the hospital, she was found to have a low body temperature and sepsis. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. On arrival to the hospital, she was found to have a low body temperature and sepsis. An immediate Jeopardy (IJ) situation was identified on 10/11/23 at 1:45 p.m. The IJ template was provided to the facility on [DATE] at 4:00 p.m. While the IJ was removed on 10/12/23 at 6:40 p.m. the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not having their physician consulted on changes in condition requiring medical intervention. caused harm and could have resulted in the death of the resident. Finding included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were chronic respiratory failure, asthma, obesity, bronchitis, unspecified dementia, high blood pressure, rheumatoid arthritis, and gout( form of arthritis characterized by severe pain) of the right knee. Record review of a quarterly MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment, and she required extensive assistance of two people with all ADLs. She required one-person extensive assist with dressing and supervision for eating. Record review of Resident #1's care plan dated 4/16/23 indicated a Focused Area of a potential for respiratory distress related to Asthma. One of the interventions was to observe for signs of respiratory distress, rapid breathing, cyanosis (bluish discoloration of skin resulting from inadequate oxygenation of the blood), shortness of breath, nasal flaring, retractions, and wheezing. Record review of Resident #1's computerized physician's orders indicated and order for BIPAP (a machine that helps breathing) to be placed at night and removed in the mornings. Ondansetron (Zofran) HCL 4m as needed for nausea and vomiting. Budesonide Inhalation suspension 0.5 mg inhale orally every 12 PRN. Record review of Resident #1's nursing note dated 9/27/23 at 5:42 p.m. indicated the resident retuned from a doctor's appointment with new orders for 5 new medications. Signed by LVN K. Record review indicated Resident#1 was given new order on 9/27/23 by a Rheumatoid Arthritis Doctor for the following medications:. Sulfasalazine 500 mg QD- side effects feeling sick nausea, vomiting, stomach pain. Neurontin 600 mg QD- side effects felling sick nausea and or vomiting. Prednisone 5mg bid - side effects decrease in the amount of urine, fast, slow, pounding, or irregular heartbeat, or pulse, rattling breathing. Tramadol HCL 50 mg every 6 hours-routine- side effect fatigue or drowsiness, loss of appetite, nausea, and vomiting. Allopurinol 100 mg QD- the most common side effect upset stomach, nausea, diarrhea, or drowsiness. Record review of Resident #1's September 2023 MAR indicated on 9/27/23 Neurontin 600 mg at 5 p.m. ( initial dose) was administered by MA M. Record review of Resident #1's nursing notes dated 9/28/23 at 12:42 a.m . indicated at 9:00 p.m. the resident stated that she went to the doctor today and got some new medications. Medication education was given related to Tramadol, 50mg for pain every 6 hours. Neurontin 600 mg two times a day, uric Acid, and Alopurinol 100 mg the resident received education on these medications. Signed by RN J. Record review of a nursing note dated 9/28/23 at 11:33 a.m. indicated the resident was give Ondansetron for nausea. At 2:00 p.m. the medication was noted to be effective. Signed by LVN K. Record review of nursing note dated 9/28/23 at 6:00 p.m. indicated the resident had no adverse effects to new medications and would continue to monitor. At 9:01 p.m. the resident was given Ondansetron for nausea. At 10:18 p.m. it was noted to be effective. Signed by LVN K. Record review of Resident #1's nursing notes dated 9/28/23 at 9:45 p.m. indicated Ondansetron (Zofran) was given for nausea. At 10:18 p.m. it was effective. At 11:35 a.m. the resident vomited Signed by RN J. Record review of nursing note dated 9/28/23 at 11:35 p.m. indicated at 9:30 p.m. rResident #1 vomited undigested food particle. O2 stat 97 percent with oxygen infusing at 2.5 liters per minute . HR 60, 18 respiration, temperature 97.4 and BP 110/77, Zofran given for nausea and vomiting. The Resident requested to leave the CPAP for now. Head of bed elevated. Will continue to monitor. Written by RN J. Record review of Resident #1's September 2023 MAR indicated: on 9/28/23 Neurontin 600 mg at 9:00 a.m. and 5 p.m. was given by MA I. Allopurinol 100 mg was given at 9:00 a.m. ( initial dose) by MA M. Sulfasalazine 500 mg was given at 9:00 a.m. ( initial dose) by MA M. Prednisone 5mg was given at bedtime ( initial dose) was given by RN J. Tramadol 50mg was given at 3:00 a.m. by RN J ( initial dose) -Tramadol 50 mg was given at 9:00 a.m. and 3:00 p.m. by MA I , and Tramadol 50 mg given at 9:00 p.m. by RN J. Record review of the Facility 24-hour report for Resident #1 on the night of 9/28/23 through 9/29/23 indicated on the 6p to 6 a shift indicated at 9:30 p.m. Resident #1 complained of nausea and vomited one time. Record review of nursing notes dated 9/29/23 at 4:32 a.m. indicated Resident #1 was asleep with the head of bed elevated and oxygen infusing at the prescribed rate. No adverse reactions noted to the new medications. Push or encourage fluids was done. Written by RN J. Record review of nursing notes dated 9/29/23 at 5:19 p.m. no adverse reaction noted to new medications give food with meds. Written by LVN E. Record review of Resident #1's September 2023 MAR indicated on 9/29/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Allopurinol 100 mg was given at 9:00 a.m. by MA X Sulfasalazine 500 mg was given at 9:00 a.m. by MA X On 9/29/23 Prednisone 5mg was given in the morning and bedtime by MA X. On 9/29/23 Tramadol 50mg was given at 3:00 a.m. by RN J -Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg for 9:00 p.m. was not administered; the MAR was blank with no reason documented for not administered. Record review of nursing notes dated 9/30/23 at 8:59 a.m. indicated day three of new medication no adverse reactions noted. Written by LVN E. Record review of nursing notes dated 9/30/23 at 7:05 p.m. Ondansetron gives for nausea at 10: 16 pm effective. Written by LVN C. Record review of Resident #1's September 2023 MAR indicated on 9/30/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Sulfasalazine 500 mg was given at 9:00 a.m. by MA X Allopurinol 100 mg was given at 9:00 a.m. by MA X Prednisone 5mg was given in the morning and bedtime by MA X. On 9/30/23 Tramadol 50 mg. At 3:00 a.m. the Tramadol was not administered; the MAR was blank with no reason documented for not administered. Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg . At 9:00 p.m. Tramadol was not administered; the MAR was blank with no reason documented for not administered. Record review of the Facility 24-hour report for Resident #1 on the night of 9/30/23 through 10/1/23 indicated on the 6p to 6 a shift the Tramadol was held due to nausea and possible reaction to the drug. There was no vomiting after 8 p.m. the resident was non-compliant with cpap, or oxygen pulled both off o2 stats remained in the upper 90 checked every hour and oxygen replaced . Record review of nurses note dated 10/1/23 at 8:45 a.m. Resident #1's family member stated the resident is not right. This nurse assessed the resident and bp was 118/72 pulse 60, respirations 18, the resident is a bit lethargic but is talking, notified the DON, instructed to send to the hospital. The resident vomited before this shift. Written by LVN E. Record Review of a nursing note dated 10/1/23 at 9:36 a.m. indicated at this time nurse was asked by LVN E to assist with patients' assessment. Upon entering the room this nurse met by family member and was brought up to date on the situation with Resident #1. When this nurse observed the patient lying on her back in bed with the head of the bed raised at 45 degrees angle, the resident appearance prompted the nurse to ask LVN E to call 911. The nurse continued with the patient's assessment pulse )O2 reading 54 percent on 2 LPM with heart rate 52. The nurse asked family member if patient had a diagnosis of COPD (constriction of air way and difficulty breathing), and she said no raised O2 to 4 liters. Blood pressure was manually taken and was 118/72 . uUpon palpating pulse, it was noted to be light and thready (difficult to feel. The Resident's lower legs were noted to be discolored with yellow splotches and cold to touch, no pulse noted to feet, popliteal ( back of the knee) pulse and the feet was the same. Light and thready. At this time EMS times 2 attendants arrived. [NAME] by LVN F Record review of nursing noted dated 10/1/23 at 7:45 p.m. indicate a late entry for 9/30/23 at 9:40 p.m. Resident #1 vomited two times and Zofran administered the resident was monitored the rest of the night with now as non-compliant with nasal cannula and the cpap r eplaced both several times oxygen stats remained over 90 precent q hour all night. Written by LVN C Record review of Resident #1's an EMS report indicated they received a call at 8:36 a.m. They arrived at the facility at 8:44 a.m. The patient was lying on her back on the bed awake and alert. She was found to be pale and cool to the touch. The patient responded to all questions appropriately but would occasionally fall asleep intermittently. She stated she felt fine and had no complains but felt tired. The nurse stated that the patient was acting lethargic (sleepy and drowsy), and she felt she was having difficulty breathing. Upon assessment the patient was found to be breathing normally but was found to have symptomatic bradycardia ( low heart rate less than 60 beats per minute). The patients' radial pulses and blood pressure was palpated ( by touch) at 70 pulses. The patient was symptomatic but was also awake and alert with no complaints. She was moved to the cot and transported to the hospital. The patient was given IV with atropine ( medication used to reduce low heart rate) 1mg after a dose of atropine the patient's heart rate increase to 55 and the blood pressure increased. The patient continuously reassessed and remained stable. Upon arrival to the hospital the patient was moved to a bed and left with the ER staff the transfer of care was at 9:20 a.m. Record review of the hospital ED Physician Documentation dated 10/1/23 indicated Resident #1 had arrived at 9:12 a.m. at 9:57 a.m. she had shortness of breath. EMS was called to the nursing home for shortness of breath. When they arrived, they found the patient did not seem to have a lot of shortness of breath. However, her vital signs found she had a heart rate in the high 20s and low 30s and was sinus on the monitor . The patients initial blood pressure was 70/40. They gave the patient 2 doses of atropine end route. When she arrived at the ER her heartrate was in the 50s and was junctional rhythm . Her blood pressure though head had decreased, and her initial blood pressures were 50s over 30s. tThe patient was still awake and alert, talking and said she felt fine. Record Review of a Critical Care Hospital and Physical dated 10/1/23 indicated. On presentation to the hospital, she was severely bradycardia with heart rate of 29. She was hypotensive ( low blood pressure), and hypothermia ( low body temperature) with a temperature of 94 degrees. She had been started on dopamine. She still required additional Levophed ( used to treat low BP) to the dopamine because of hypotension. She was given Maxipine ( used to treat infections) in the ER for probable sepsis. Her urine output was extremely poor with Foley placed in the ER. The impression was Sepsis ( harmful microorganisms in the blood), Anemia, Bradycardia , and acute urinary tract infection. The plan was to gently warm the patient while treating for sepsis with antibiotic and IV fluids. The patient will be intubated (insertion of a tube down the mouth or nose into the windpipe to open airways) and mechanically ventilated. The patient is unstable and was critically ill with life in imminent threat . Record review of a Grievance Complaint Report dated 10/1/23 indicated the Family member of Resident # 1 made a report to the Administrator and the DON that indicated the LVN E did not send Resident #1 to the Hospital in a timely manner. The actions taken was a one-on-one meeting with the charge nurse. Record review of Resident #1's nursing notes dated 10/2/23 at 8:05 a.m. indicated the nurse called the hospital for an update on the resident condition. The nurse was informed the resident was intubated in ICU with no date of discharge at this time. [NAME] by LVN K During an interview on 10/3/23 at 9:59 a.m. the DON said they had received a complaint from the family member of Resident #1. She said the family member complained that it took LVN E too long to send Resident #1 to the hospital on [DATE]. The DON said Resident #1's blood pressure was normal, but her oxygen level was low. They had sent her to the hospital, they knew she was in ICU because the family member said as much, but they did not know the status of Resident #1. The DON said she did an in service with LVN E and investigated the allegations but did not have hospital records. During an interview on 10/3/23 at 10:45 a.m. Resident #3 ( roommate to Resident #1) said the staff were all saying they thought Resident was sick because of her new medications. Resident #3 said on Saturday, 9/30/23 Resident #1 was real quite all day. She said on Saturday after the family member left Resident #1 started throwing up and when they got her cleaned up and she would throwed up again. Resident #3 said when they were all in the room the CNA A told the LVN C Resident #1 needed to go to the hospital. Resident said over in the night Resident #1 was talking out of her head to someone named sis and that was unusual. During an interview on 10/3/23 at 10:50 CNA H said she worked from 6 a to 12 p.m. on Saturday 9/30/23 . She said while she was at work Resident#1 did not throw up that day, but she had thrown up the night before because her sheets, blanket, and gown had vomit on them. She had cleaned her up and told LVN E. CNA H said Resident #1 said she was not feeling well and had thrown up. She said on Sunday 10/1/23 she arrived at work at 6:00 a.m. and saw LVN E come out of Resident #1's room about 6:30 a.m. She said when she went in the room about 7:20 a.m. or so the family member was in the room. The resident had thrown up and they started to clean her up. CNA H said the family member went and got LVN E to take Resident #1's blood pressure and the nurse could not. She fumbled around for about an hour and the family member just wanted Resident #1 sent to the hospital. The aide said she told LVN E Resident #1 needed to go to the hospital because she was not herself. She said the LVN E acted like she did not want to send the Resident to the hospital . CNA H said LVN E finally went and got LVN F and LVN A left the room. She said EMS arrived a few minutes later and Resident #1 was taken to the hospital. During an interview on 10/3/23 at 11:03 a.m. CNA G said she worked the weekend and Resident #1 was sick on Saturday. She said the resident was not really a complainer, she was just not herself and she would not eat. CNA G said she told LVN E on Saturday, 9/30/23 several times Resident #1 was not feeling well and not eating. She said she arrived to work at 6:00 on 10/1/23. She said Resident #1 refused her breakfast and was groggy. She said LVN E knew she was not feeling well the last few days. CNA G said around 7:20 a.m. the family member came and told us she had thrown up on 9/29/23 at night. We ( me and CNA H) told LVN E-to send Resident #1 out, but it was not until about 9:00 a.m. when Resident #1 was sent to the hospital. She said LVN E did not want to send Resident #1 out and the family member said she needed to go to the hospital several times. During an interview on 10/3/23 at 11:14 a.m. LVN F said she worked Sunday 10/1/23 at the other nurse's station. She said on 10/1/23 she saw a patient she never met before. She said LVN E came and got her to assist with the assessment of Resident #1 and to help her make the decision whether to send the resident to the hospital or not. LVN F said LVN E could not find a pulse Ox . LVN F said she had her own. She said LVN E was not familiar with central supply closet where they kept the little crash cart that had everything, such as blood pressure cup and pulse Ox. LVN F sad LVN E had already came and gotten another nurse's manual blood pressure cup from the other nurse's station. LVN F said what she saw when she entered Resident #1's room was an African American female whose skin was grayish. She said the moment she walked into the room told LVN E to call 911. LVN F said Resident #1's lower legs to knees were cold and she looked almost white, her 02-level was 54 percent on 2 liters of oxygen, and heart rate 52. She said she asked the family member to turn the oxygen up to 4 liters, because she was on that side of the bed and she watched where she put the level. LVN F said her check of Resident #1's blood pressure was 118/72 and the 72 was very light., her pulse was weak and thready. She said Resident #1 opened her eyes and winked at her but never spoke a word. LVN F said she counted 12 respirations a minute. She said she was told LVN E had come to get her once and the family member had come to get her, but she was in a room. She said she the aides had told her they had told LVN E to send Resident #1 to the hospital the day before. LVN F said shortly after they left with Resident #1 the family member called and said they had put Resident #1 in ICU. She said when LVN E came and got her, she left the room to call 911, she never came back. She said EMS took Resident #1's blood sugars and they were 132. During an interview on 10/3/23 at 11: 20 a.m. the family member of Resident #1 said they had come to the facility on Saturday evening and the resident was drowsy and not eating. She had thrown up her food. She said she had already thrown up because there was vomit in the trash can. The family member said Resident#1's gown and everything had vomit on it. She said prior to leaving she asked the nurse LVN C not to give her the night dose of tramadol because she was so sleepy. The family member said on Sunday morning she had come early because she wanted to see how Resident #1 was doing. The family member said arrived about 7:30 a.m. Resident #1 was so sleepy she could hardly talk. The family member said she went and got LVN E to take her blood pressure and LVN E could not find a blood pressure cup that worked the battery was low or something. The family member said after about 30 minutes LVN E went and got a manual blood pressure cup. The family member said when LVN E took Resident #1's blood pressure the family member said they did not believe LVN E knew what she was doing the blood pressure was 117/72. The family member asked for an oxygen status, and for a second opinion or to just send Resident #1 to the hospital. The family member said after about 30 more minutes LVN F accompanied LVN E in the room. The family member said LVN F took one look at the Resident #1 and told to LVN E to send her to the hospital. The family member said LVN E left the room, and she did not come back that she remembered. The family member said Resident #1's feet were cold and when she got to the hospital, they had to warm her body up because she was cold. The family member said LVN F was able to take Resident #1's oxygen status and it was low. The family member said when the resident arrived at the hospital her oxygen level was 52 and her bp was 88/53. The family member said at when the nursing home took it manually it was 117/72 and they did not do it right. The family member said the aides said they had told LVN E, the resident did not look good and needed to go to the hospital, but she would not listen. The family member said at the hospital they put the catheter in Resident #1 and got no urine output. The family member said when Resident #1 arrived at the hospital they said she was septic, the had to put some type of warming blanket on her, and they had intubated the resident and put her in ICU, she was not doing well at the current time. During an interview on 10/3/23 at 11:40 a.m. the DON said the family member was upset because she felt the resident was not sent to the hospital timely. She said LVN E called her to say Resident #1's O2 stat was low, and she was kind of lethargic. She said told her the family wanted Resident #1 sent to the hospital, and she had told her if the family wanted her sent out then send her out. The DON said she called LVN E to check on Resident #1 and did a follow up to make sure the resident had gotten to the hospital. She said someone said something about the resident had thrown up, during morning meeting on Friday, 9/29/23, but she was not aware Resident #1 continued vomiting. During an interview on 10/3/23 at 12:35 p.m. the NP said on 9/29/23 she was informed Resident#1 had thrown up on Friday during morning meeting. She said she worked at the facility Monday through Friday and if there were any issues the staff notified her. If she had questions or concerns, she would notify the physician. She said she was only informed that one time Resident #1 had vomited. She said she was not informed the resident continued to throw up the next two days. She said Resident #1 went to a Rheumatoid doctor on 9/27/23 and came back with prescriptions for 5 different medications. She said she told the nursing staff to make sure Resident #1 ate before giving her the medications and no one informed her she continued to throw up. The NP said the resident continued vomiting could have been due to the new medications. She said if she had been informed the resident was throwing up for 3 days, she would have requested labs, pushed fluids, and looked at some other interventions for the resident. If she continued to vomit, she would have sent her to the hospital for an evaluation. During an interview on 10/3/23 at 1:05 p.m . the DON said that she would look for the one on one in service she had conducted with LVN E. She then said she had conducted the interview over the phone and did not have it written down at the current time. During an interview on 10/4/23 at 9:25 a.m. LVN E said she had worked at the facility for 4 days and on Sunday 10/1/23, it was her third time working with Resident #1. She said she did not remember the aides telling her anything about Resident #1 being sick and not eating. She said she had not consulted with the physician or the NP during the weekend . She said after she sent Resident #1 to the hospital, she had sent the NP a text. She said when she came in and the nurse on the night shift said Resident #1 had vomited. She went to the room to check the roommates blood sugars. She walked over to Residen#1's side of the room and touched her hand, and the resident was doing fine, she did not note anything out of the ordinary. She said around 7:30 a.m. or so the resident's family member came and asked her to check Resident #1's blood pressure. She said the batteries were down in the one she had, and she could not find another one. She had gone to the nurse's station on the other hall and gotten one a manual BP cup from a coworker. She said Resident #1's BP was 117/70. Pulse 60 and R 18. The family member told her she wanted someone else to do it. She went and got the nurse from across the way. She said that nurse had a pulse Ox, and she could not find one. She said the residents O2 stat was 50 and she left to call 911. She said she did call the DON first and then 911. She said the resident temp was 97 . She said her feet were cold she had stayed in the room probably 20 minutes with the family member and Resident #1. During an observation and interview on 10/4/23 at 1:00 p.m. at the hospital with Resident #1 and the ICU nurse. Resident #1 was observed in the ICU in a hospital bed. She was laying on her back with monitors hooked up and IVs flowing. She was awake and fidgety. She shook her head yes when asked if she had been sick a few days prior to coming to the nursing home. The only other communication was she whispered her name. The ICU RN said her intubation was removed yesterday. He said she appeared to have decreased memory and more confusion. Observation of Resident #1 wanted the nurse to open the suction tubing for her to suction her throat, several times she kept repeating open. She was coughing up mucus and wanted to continue to use the tube. The RN explained to her several times she was clear and did not need the tube. Resident #1 did calm down a appeared to rest. The nurse said they did not have any discharge plans for the resident at this time. During a telephone interview on 10/5/23 at 3:20 a.m. LVN C said she worked Saturday, 9/30/23 night going into Sunday, 10/1/23 morning. She said on the Saturday evening about 8 p.m. the family member came and told her Resident #1 was nauseated, she gave her some Zofran and she threw that up. She gave her another one and put that one under her tongue and the resident went to sleep. She said she checked on her all through the night and kept putting the oxygen on her. She said about 3:00 a.m. the resident said she wanted to get up, but she did not. She said on Sunday morning she went in to check on her and she was fine she said she gave her a routine breathing treatment, she did not have any breathing issues and her O2 stat was never under 90. Said the aides did tell her she was none responsive around 5:30 a.m., but when they went in to check on about 5:45 a.m. she was talking. She said she took her O2 stats at that time but did not write them down. She told the oncoming nurse to check on her because she was not feeling well and to keep check on her O2 status. She said the resident's status had changed since they put her on the new medications. She had held the tramadol because she was so sleepy. She had put on the MAR refused because there were only so many choices. She said she had put that information on the 24-hour report. During a telephone interview on 10/5/23 at 3:26 a.m. with CNA A said she worked at the facility for about a month. On Friday night Resident#1 complained of being nauseous. She said when she came in Saturday at 6:00 p.m. about two hours into the shift she said Resident #1 was nauseated and she threw up several times. The last time she saw her was about 5:30 a.m. on 10/1/23 when she and CNA B went in to change her. CNA A said Resident #1 was not coherent. She said they tried to wake her up and could not. She said they told LVN C about the Resident #1's condition. CNA A said Resident #1 had her oxygen on at that time, and the oxygen was on around 3:00 a.m. when they had gone into the room. During a telephone interview on 10/5/23 at 3:29 a.m. CNA B said he worked at the facility for 7 years. He said on Friday night the Resident #1 was fine but complained of being nauseated. He said Resident #1 was a two person assist and most of the time when CNA A went into the room, he was with her. He said Resident #1 was sick all-night Saturday, 9/30/23 they told the nurse several times. He said about 5:30 a.m. when then did the last round Resident #1 seemed dead. They could not get her to open her eyes, they changed her and told the nurse. She had her oxygen on at that time. During an interview on 10/5/23 at 5:53 a.m. CNA A said they had informed LVN C several times on Saturday night Resident #1was sick. She said she never saw her go into her room. She said Resident #1 was wet each time they went into change her and she had her oxygen on. She said what they did to Resident #1 was not right. They knew she was sick all weekend and did nothing. A statement written by CNA A dated 10/5/23 indicated on Friday 9/29/23 Resident #1 was responsive and said she was nauseated. On Saturday, 9/30/23 Resident #1 was responsive at 6:00 p.m. and complaining about being nauseated. She started throwing up around 8-8:30 p.m. as the night progressed, she started to get worse. She said we, ( Me and CNA B) told LVN C she needed to go to the hospital. CNA A said LVN C said she was going to give her some more anti-nausea pills. She said around 5:30 a.m. Resident #1 was incoherent and they ( she and CNA B) could not wake her up. She said they told LVN C. She said LVN C went to check on Resident #1 one time when she was throwing up and did not go back to check on her during the night. During an interview on 10/5/23 at 5:57 a.m. CNA B said when they went in to change Resident #1 her brief was wet. He said she was different and sick for the last couple of nights. He said they all thought it was because of the new medications they had given her because she was not like that before. He said they told LVN A several times that night and that morning the resident was sick. He said at 5:30 a.m. they told LVN C, Resident #1 was not responsive. He said he never saw her move to go toward her room. During an interview on 10/5/23 at 6:10 a.m. LVN C said she had held Residents #1'sTramadol on the night of 10/1/23 because she was throwing up and she felt it had something to do with the medications. She had not called the physician with any of her concerns. During an interview on 10/5/23 at 7:00 a.m. LVN E said on 10/1/23 when the night nurse ( LVN C) left, she told her Resident #1 had been throwing up. She said LVN E said she had looked in on Resident #1 and she was okay. She said she did not give her any medications that morning before she left for the hospital, the medication aide gave the medications. The medication aide did not arrive until 8:00 a.m. LVN E said Resident #1 could have been having a reaction to the medications. She said the nurses were the ones that wrote the notes in the chart about no adverse reactions to the medications. She thought it was somewhere on the nurse MAR that they put that information. During an interview with on 10/5/23 at 8:30 a.m. MA I said she did not write anything in the cart about adverse reactions to medications, that was the nurses that did that . She said Resident #1 had some new medications and she gave them as prescribed. She said Resident #1 always took her medication without any problems. MA I said she did not know anything about Resident #1 being sick. During an interview on 10/11/23 at 2:55 p.m. the DON said it was the facility policy that nurses give the initial dose of new medications to residents. She said after that the MAs give the medication, but the nurses are to check for adverse reactions to the medications. She said it was her policy that the nurses notify her of any change in condition before they send someone out to the hospital. She said if the family request the nurses send them out and call her after. She said she had a procedure written down that she gave to nurses on hire. During an interview on 10/11/23[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care.(Resident #1), in that: The facility failed to ensure Resident #1 was not having adverse reactions to new medication. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. They failed to assess Resident #1 and notify the physician when she experienced adverse reaction to new medications. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. On arrival to the hospital, she was found to have a low body temperature and sepsis. An immediate Jeopardy (IJ) situation was identified on 10/11/23 at 1:45 p.m. The IJ template was provided to the facility on [DATE] at 4:00 p.m. While the IJ was removed on 10/12/23 at 6:40 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not receiving care and services to meet their needs caused harm and could have resulted in the death of the resident. Finding included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were chronic respiratory failure, asthma, obesity, bronchitis, unspecified dementia, high blood pressure, rheumatoid arthritis, and gout( form of arthritis characterized by severe pain) of the right knee. Record review of a quarterly MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment, and she required extensive assistance of two people with all ADLs. She required one-person extensive assist with dressing and supervision for eating. Record review of Resident #1's care plan dated 4/16/23 indicated a Focused Area of a potential for respiratory distress related to Asthma. One of the interventions was to observe for signs of respiratory distress, rapid breathing, cyanosis(bluish discoloration of skin resulting from inadequate oxygenation of the blood), shortness of breath, nasal flaring, retractions, and wheezing. Record review of Resident #1's computerized physician's orders indicated and order for BIPAP (a machine that helps breathing) to be placed at night and removed in the mornings. Ondansetron(Zofran) HCL 4m as needed for nausea and vomiting. Budesonide Inhalation suspension 0.5 mg inhale orally every 12 PRN. Record review of Resident #1's nursing note dated 9/27/23 at 5:42 p.m. indicated the resident retuned from a doctor's appointment with new orders for 5 new medications. Signed by LVN K. Record review indicated Resident#1 was given new order on 9/27/23 by a Rheumatoid Arthritis Doctor for the following medications. Sulfasalazine 500 mg QD- side effects feeling sick nausea, vomiting, stomach pain. Neurontin 600 mg QD- side effects felling sick nausea and or vomiting. Prednisone 5mg bid- side effects decrease in the amount of urine, fast, slow, pounding, or irregular heartbeat, or pulse, rattling breathing. Tramadol HCL 50 mg every 6 hours-routine- side effect fatigue or drowsiness, loss of appetite, nausea, and vomiting. Allopurinol 100 mg QD- the most common side effect upset stomach, nausea, diarrhea, or drowsiness. Record review of Resident #1's September 2023 MAR indicated on 9/27/23 Neurontin 600 mg at 5 p.m. ( initial dose) was administered by MA M. Record review of Resident #1's nursing notes dated 9/28/23 at 12:42 a.m. indicated at 9:00 p.m. the resident stated that she went to the doctor today and got some new medications. Medication education was given related to Tramadol, 50mg for pain every 6 hours. Neurontin 600 mg two times a day, uric Acid, and Alopurinol 100 mg the resident received education on these medications. Signed by RN J. Record review of a nursing note dated 9/28/23 at 11:33 a.m. indicated the resident was give Ondansetron for nausea. At 2:00 p.m. the medication was noted to be effective. Signed by LVN K. Record review of nursing note dated 9/28/23 at 6:00 p.m. indicated the resident had no adverse effects to new medications and would continue to monitor. At 9:01 p.m. the resident was given Ondansetron for nausea. At 10:18 p.m. it was noted to be effective. Signed by LVN K. Record review of Resident #1's nursing notes dated 9/28/23 at 9:45 p.m. indicated Ondansetron (Zofran) was given for nausea. At 10:18 p.m. it was effective. At 11:35 a.m. the resident vomited Signed by RN J. Record review of nursing note dated 9/28/23 at 11:35 p.m. indicated at 9:30 p.m. resident #1 vomited undigested food particle. O2 stat 97 percent with oxygen infusing at 2.5 liters per minute. HR 60, 18 respiration, temperature 97.4 and BP 110/77 Zofran given for nausea and vomiting. The Resident requested to leave the CPAP for now. Head of bed elevated. Will continue to monitor. Written by RN J. Record review of Resident #1's September 2023 MAR indicated: on 9/28/23 Neurontin 600 mg at 9:00 a.m. and 5 p.m. was given by MA I. Allopurinol 100 mg was given at 9:00 a.m. ( initial dose) by MA M. Sulfasalazine 500 mg was given at 9:00 a.m. ( initial dose) by MA M. Prednisone 5mg was given at bedtime ( initial dose) was given by RN J. Tramadol 50mg was given at 3:00 a.m. by RN J ( initial dose) -Tramadol 50 mg was given at 9:00 a.m. and 3:00 p.m. by MA I , and Tramadol 50 mg given at 9:00 p.m. by RN J. Record review of the Facility 24-hour report for Resident #1 on the night of 9/28/23 through 9/29/23 indicated on the 6p to 6 a shift indicated at 9:30 p.m. Resident #1 complained of nausea and vomited one time. Record review of nursing notes dated 9/29/23 at 4:32 a.m. indicated Resident #1 was asleep with the head of bed elevated and oxygen infusing at the prescribed rate. No adverse reactions noted to the new medications. Push or encourage fluids was done. Written by RN J. Record review of nursing notes dated 9/29/23 at 5:19 p.m. no adverse reaction noted to new medications give food with meds. Written by LVN E. Record review of Resident #1's September 2023 MAR indicated on 9/29/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Allopurinol 100 mg was given at 9:00 a.m. by MA X Sulfasalazine 500 mg was given at 9:00 a.m. by MA X On 9/29/23 Prednisone 5mg was given in the morning and bedtime by MA X. On 9/29/23 Tramadol 50mg was given at 3:00 a.m. by RN J -Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg for 9:00 p.m. was not administered the MAR was blank with no reason documented for not being administered. Record review of nursing notes dated 9/30/23 at 8:59 a.m. indicated day thee of new medication no adverse reactions noted. Written by LVN E. Record review of nursing notes dated 9/30/23 at 7:05 p.m. Ondansetron [NAME] for nausea at 10: 16 pm effective. Written by LVN C. Record review of Resident #1's September 2023 MAR indicated on 9/30/23 MA X administered Neurontin 600 mg at 9:00 a.m. and 5 p.m. Sulfasalazine 500 mg was given at 9:00 a.m. by MA X Allopurinol 100 mg was given at 9:00 a.m. by MA X Prednisone 5mg was given in the morning and bedtime by MA X. On 9/30/23 Tramadol 50 mg. At 3:00 a.m. the Tramadol was not administered; the MAR was blank with no reason documented for not being administered. Tramadol 50 mg given at 9:00 a.m. and 3:00 p.m. by MA X, and Tramadol 50 mg . At 9:00 p.m. Tramadol was not administered the MAR was blank with no reason documented for not being administered. Record review of the Facility 24-hour report for Resident #1 on the night of 9/30/23 through 10/1/23 indicated on the 6p to 6 a shift the Tramadol was held due to nausea and possible reaction to the drug . There was no vomiting after 8 p.m. the resident was non-compliant with cpap, or oxygen pulled both off o2 stats remained in the upper 90 checked every hour and oxygen replaced. Record review of nurses note dated 10/1/23 at 8:45 a.m. Resident #1's family member stated the resident is not right. This nurse assessed the resident and bp 118/72 pulse 60, respirations 18, the resident is a bit lethargic but is talking, notified the DON, instructed to send to the hospital. The resident vomited before this shift. Written by LVN E. Record Review of a nursing note dated 10/1/23 at 9:36 a.m. (late entry) indicated at this time nurse was asked by LVN E to assist with patients' assessment. Upon entering the room this nurse met by family member and was brought up to date on the situation with Resident #1. When this nurse observed the patient lying on her back in bed with the head of the bed raised at 45 degrees angle, the resident appearance prompted the nurse to ask LVN E to call 911. The nurse continued with the patient's assessment pulse )O2 reading 54 percent on 2 LPM with heart rate 52. The nurse asked family member if patient had a diagnosis of COPD (constriction of air way and difficulty breathing), and she said no raised O2 to 4 liters. Blood pressure was manually taken and was 118/72 . uUpon palpating pulse, it was noted to be light and thready (difficult to feel. The Resident's lower legs were noted to be discolored with yellow splotches and cold to touch, no pulse noted to feet, popliteal ( back of the knee) pulse and the feet was the same. Light and thready. At this time EMS times 2 attendants arrived. [NAME] by LVN F Record review of nursing noted dated 10/1/23 at 7:45 p.m. indicate a late entry for 9/30/23 at 9:40 p.m. Resident #1 vomited two times and Zofran administered the resident was monitored the rest of the night as non compliant with nasal cannula and the cpap CPAP replaced both several times oxygen stats remained over 90 precent q hour all night. Written by LVN C Record review of Resident #1's an EMS report indicated they received a call at 8:36 a.m . They arrived at the facility at 8:44 a.m. The patient was lying on her back on the bed awake and alert. She was found to be pale and cool to the touch. The patient responded to all questions appropriately but would occasionally fall asleep intermittently. She stated she felt fine and had no complains but felt tired. The nurse stated that the patient was acting lethargic (sleepy and drowsy), and she felt she was having difficulty breathing. Upon assessment the patient was found to be breathing normally but was found to have symptomatic bradycardia ( low heart rate less than 60 beats per minute). The patients' radial pulses and blood pressure was palpated ( by touch) at 70 pulses. The patient was symptomatic but was also awake and alert with no complaints. She was moved to the cot and transported to the hospital. The patient was given IV with atropine( medication used to reduce low heart rate) 1mg after a dose of atropine the patient's heart rate increase to 55 and the blood pressure increased. The patient continuously reassessed and remained stable. Upon arrival to the hospital the patient was moved to a bed and left with the ER staff the transfer of care was at 9:20 a.m. Record review of the hospital ED Physician Documentation dated 10/1/23 indicated Resident #1 had arrived at 9:12 a.m. at 9:57 a.m. she had shortness of breath. EMS was called to the nursing home for shortness of breath. When they arrived, they found the patient did not seem to have a lot of shortness of breath. However, her vital signs found she had a heart rate in the high 20s and low 30s and was sinus on the monitor. The patients initial blood pressure was 70/40. They gave the patient 2 doses of atropine end route. When she arrived at the ER her heartrate was in the 50s and was junctional rhythm . Her blood pressure though head decreased, and her initial blood pressures were 50s over 30s. the patient was still awake and alert, talking and said she felt fine. Record Review of a Critical Care Hospital and Physical dated 10/1/23 indicated. On presentation to the hospital, she was severely bradycardia with heart rate of 29. She was hypotensive ( low blood pressure), and hypothermia( low body temperature) with a temperature of 94 degrees. She had been started on dopamine. She still required additional Levophed( used to treat low BP) to the dopamine because of hypotension. She was given Maxipine ( used to treat infections) in the ER for probable sepsis. Her urine output was extremely poor with Foley placed in the ER. The impression was Sepsis( harmful microorganisms in the blood), Anemia, Bradycardia , and acute urinary tract infection. The plan was to gently warm the patient while treating for sepsis with antibiotic and IV fluids. The patient will be intubated(insertion of a tube down the mouth or nose into the windpipe to open airways) and mechanically ventilated. The patient is unstable and was critically ill with life in imminent threat . Record review of a Grievance Complaint Report dated 10/1/23 indicated the Family member of Resident # 1 made a report to the Administrator and the DON that indicated the LVN E did not send Resident #1 to the Hospital in a timely manner. The actions taken was a one-on-one meeting with the charge nurse. Record review of Resident #1's nursing notes dated 10/2/23 at 8:05 a.m. indicated the nurse called the hospital for an update on the resident condition. The nurse was informed the resident was intubated in ICU with no date of discharge at this time. [NAME] by LVN K. During an interview on 10/3/23 at 9:59 a.m. the DON said they had received a complaint from the family member of Resident #1. She said the family member complained that it took LVN E too long to send Resident #1 to the hospital on [DATE]. The DON said Resident #1's blood pressure was normal, but her oxygen level was low. They had sent her to the hospital, they knew she was in ICU because the family member said as much, but they did not know the status of Resident #1. The DON said she did an in service with LVN E and investigated the allegations but did not have hospital records. During an interview on 10/3/23 at 10:45 a.m. Resident #3 ( roommate to Resident #1) said the staff were all saying they thought Resident was sick because of her new medications. Resident #3 said on Saturday, 9/30/23 Resident #1 was real quite all day. She said on Saturday after the family member left Resident #1 started throwing up and when they got her cleaned up and she would throwed up again. Resident #3 said when they were all in the room the CNA A told the LVN C Resident #1 needed to go to the hospital. Resident said over in the night Resident #1 was talking out of her head to someone named sis and that was unusual. During an interview on 10/3/23 at 10:50 CNA H said worked from 6 a to 12 p.m. on Saturday 9/30/23 . She said while she was at work Resident#1 did not throw up that day, but she had thrown up the night before because her sheets, blanket, and gown had vomit on them. She had cleaned her up and told LVN E. CNA H said Resident #1 said she was not feeling well and had thrown up. She said on Sunday 10/1/23 she arrived at work at 6:00 a.m. and saw LVN E come out of Resident #1's room about 6:30 a.m. She said when she went in the room about 7:20 a.m. or so the family member was in the room. The resident had thrown up and they started to clean her up. CNA H said the family member went and got LVN E to take Resident #1's blood pressure and the nurse could not. She fumbled around for about an hour and the family member just wanted Resident #1 sent to the hospital. The aide said she told LVN E Resident #1 needed to go to the hospital because she was not herself. She said the LVN E acted like she did not want to send the Resident to the hospital . CNA H said LVN E finally went and got LVN F and LVN A left the room. She said EMS arrived a few minutes later and Resident #1 was taken to the hospital. During an interview on 10/3/23 at 11:03 a.m. CNA G said she worked the weekend and Resident #1 was sick on Saturday. She said the resident was not really a complainer, she was just not herself and she would not eat. CNA G said she told LVN E on Saturday, 9/30/23 several times Resident #1 was not feeling well and not eating. She said she arrived to work at 6:00 on 10/1/23. She said Resident #1 refused her breakfast and was groggy. She said LVN E knew she was not feeling well the last few days. CNA G said around 7:20 a.m. the family member came, and told us she had thrown up on 9/29/23 at night. We ( me and CNA H) told LVN E-to send Resident #1 out, but it was not until about 9:00 a.m. when Resident #1 was sent to the hospital. She said LVN E did not want to send Resident #1 out and family member said she needed to go to the hospital several times. During an interview on 10/3/23 at 11:14 a.m. LVN F said she worked Sunday 10/1/23 at the other nurse's station. She said on 10/1/23 she saw a patient she never met before. She said LVN E came and got her to assist with the assessment of Resident #1 and to help her make the decision whether to send the resident to the hospital or not. LVN F said LVN E could not find a pulse Ox . LVN F said she had her own. She said LVN E was not familiar with central supply closet where they kept the little crash cart that had everything, such as blood pressure cup and pulse Ox. LVN F sad LVN E had already came and gotten another nurse's manual blood pressure cup from the other nurse's station. LVN F said what she saw when she entered Resident #1's room was an African American female whose skin was grayish. She said the moment she walked into the room told LVN E to call 911. LVN F said Resident #1's lower legs to knees were cold and she looked almost white, her 02-level was 54 percent on 2 liters of oxygen, and heart rate 52. She said she asked the family member to turn the oxygen up to 4 liters, because she was on that side of the bed and she watched where she put the level. LVN F said her check of Resident #1's blood pressure was 118/72 and the 72 was very light., her pulse was weak and thready. She said Resident #1 opened eyes and winked at her but never spoke a word. LVN F said she counted 12 respirations a minute. She said she was told LVN E had come to get her once and the family member had come to get her, but she was in a room. She said she the aides had told her they had told LVN E to send Resident #1 to the hospital the day before. LVN F said shortly after they left with Resident #1 the family member called and said they had put Resident #1 in ICU. She said when LVN E came and got her, she left the room to call 911, she never came back. She said EMS took Resident #1's blood sugars and they were 132. During an interview on 10/3/23 at 11: 20 a.m. the family member of Resident #1 said they had come to the facility on Saturday evening and the resident was drowsy and not eating. She had thrown up her food. She said she had already thrown up because there was vomit in the trash can. The family member said Resident#1's gown and everything had vomit on it. She said prior to leaving she asked the nurse LVN C not to give her the night dose of tramadol because she was so sleepy. The family member said on Sunday morning she had come early because she wanted to see how Resident #1 was doing. The family member said arrived about 7:30 a.m. Resident #1 was so sleepy she could hardly talk. The family member said she went and got LVN E to take her blood pressure and LVN E could not find a blood pressure cup that worked the battery was low or something. The family member said after about 30 minutes LVN E went and got a manual blood pressure cup. The family member said when LVN E took Resident #1's blood pressure the family member said they did not believe LVN E knew what she was doing the blood pressure was 117/72. The family member asked for an oxygen status, and for a second opinion or to just send Resident #1 to the hospital. The family member said after about 30 more minutes LVN F accompanied LVN E in the room. The family member said LVN F took one look at the Resident #1 and told to LVN E to send her to the hospital. The family member said LVN E left the room, and she did not come back that she remembered. The family member said Resident #1's feet were cold and when she got to the hospital, they had to warm her body up because she was cold. The family member said LVN F was able to take Resident #1's oxygen status and it was low. The family member said when the resident arrived at the hospital her oxygen level was 52 and her bp 88/53. The family member said at the nursing home took it manually it was 117/72 and they did not do it right. The family member said the aides said they had told LVN E, the resident did not look good and needed to go to the hospital, but she would not listen. The family member said at the hospital they put the catheter in Resident #1 and got no urine output. The family member said when Resident #1 arrived at the hospital they said she was septic, the had to put some type of warming blanket on her, and they had intubated the resident and put her in ICU, she was not doing well at the current time. During an interview on 10/3/23 at 11:40 a.m. the DON said the family member was upset because she felt the resident was not sent to the hospital timely. She said LVN E called her to say Resident #1's O2 stat was low, and she was kind of lethargic. She said told her the family wanted Resident #1 sent to the hospital, and she had told her if the family wanted her sent out then send her out. The DON said she called LVN E to check on Resident #1 and did a follow up to make sure the resident had gotten to the hospital. She said someone said something about the resident had thrown up, during morning meeting on Friday, 9/29/23, but she was not aware Resident #1 continued vomiting. During an interview on 10/3/23 at 12:35 p.m. NP said on 9/29/23 she was informed Resident#1 had thrown up on Friday during morning meeting. She said she worked at the facility Monday through Friday and if there were any issues the staff notified her. If she had questions or concerns, she would notify the physician. She said she was only informed that one time Resident #1 had vomited. She said she was not informed the resident continued to throw up the next two days. She said Resident #1 went to a Rheumatoid doctor on 9/27/23 and came back with prescriptions for 5 different medications. She said she told the nursing staff to make sure Resident #1 ate before giving her the medications and no one informed her she continued to throw up. The NP said the resident continued vomiting could have been due to the new medications. She said if she had been informed the resident was throwing up for 3 days, she would have requested labs, pushed fluids, and looked at some other interventions for the resident. If she continued to vomit, she would have sent her to the hospital for an evaluation. During an interview on 10/3/23 at 1:05 p.m. the DON said that she would look for the one on one in service she had conducted with LVN E. She then said she had conducted the interview over the phone and did not have it written down at the current time. During an interview on 10/4/23 at 9:25 a.m. LVN E said she had worked at the facility for 4 days and on Sunday 10/1/23, it was her third time working with Resident #1. She said she did not remember the aides telling her anything about Resident #1 being sick and not eating. She said she had not consulted with the physician or the NP during the weekend. She said after she sent Resident #1 to the hospital, she had sent the NP a text. She said when she came in and the nurse on the night shift said Resident #1 had vomited. She went to the room to check the roommates blood sugars. She walked over to Residen#1's side of the room and touched her hand, and the resident was doing fine, she did not note anything out of the ordinary. She said around 7:30 a.m. or so the resident's family member came and asked her to check Resident #1's blood pressure. She said the batteries were down in the one she had, and she could not find another one. She had gone to the nurse's station on the other hall and gotten one a manual BP cup from a coworker. She said Resident #1's BP was 117/70. Pulse 60 and R 18. The family member told her she wanted someone else to do it. She went and got the nurse from across the way. She said that nurse had a pulse Ox, and she could not find one. She said the residents O2 stat was 50 and she left to call 911. She said she did call the DON first and then 911. She said the resident temp was 97 . She said her feet were cold she had stayed in the room probably 20 minutes with the family member and Resident #1. During an observation and interview on 10/4/23 at 1:00 p.m. at the hospital with Resident #1 and the ICU nurse. Resident #1 was observed in the ICU in a hospital bed. She was laying on her back with monitors hooked up and IVs flowing. She was awake and fidgety. She shook her head yes when asked if she had been sick a few days prior to coming to the nursing home . The only other communication was she whispered her name. The ICU RN said her intubation was removed yesterday. He said she appeared to have decreased memory and more confusion. Observation of Resident #1 wanted the nurse to open the suction tubing for her to suction her throat, several times she kept repeating open. She was coughing up mucus and wanted to continue to use the tube. The RN explained to her several times she was clear and did not need the tube. Resident #1 did calm down a appeared to rest. The nurse said they did not have any discharge plans for the resident at this time. During a telephone interview on 10/5/23 at 3:20 a.m. LVN C said she worked Saturday, 9/30/23 night going into Sunday, 10/1/23 morning. She said on the Saturday evening about 8 p.m. the family member came and told her Resident #1 was nauseated, she gave her some Zofran and she threw that up. She gave her another one and put that one under her tongue and the resident went to sleep. She said she checked on her all through the night and kept putting the oxygen on her. She said about 3:00 a.m. the resident said she wanted to get up, but she did not. She said on Sunday morning she went in to check on her and she was fine she said she gave her a routine breathing treatment, she did not have any breathing issues and her O2 stat was never under 90. Said the aides did tell her she was none responsive around 5:30 a.m., but when they went in to check on about 5:45 a.m. she was talking. She said she took her O2 stats at that time but did not write them down. She told the oncoming nurse to check on her because she was not feeling well and to keep check on her O2 status. She said the resident's status had changed since they put her on the new medications. She had held the tramadol because she was so sleepy. She had put on the MAR refused because there were only so many choices. She said she had put that information on the 24-hour report. During a telephone interview on 10/5/23 at 3:26 a.m. with CNA A said she worked at the facility for about a month. On Friday night Resident#1 complained of being nauseous. She said when she came in Saturday at 6:00 p.m. about two hours into the shift she said Resident #1 was nauseated and she threw up several times. The last time she saw her was about 5:30 a.m. on 10/1/23 when she and CNA B went in to change her. CNA A said Resident #1 was not coherent. She said they tried to wake her up and could not. She said they told LVN C about the Resident #1's condition. CNA A said Resident #1 had her oxygen on at that time, and the oxygen was on around 3:00 a.m. when the had gone into the room. During a telephone interview on 10/5/23 at 3:29 a.m. CNA B said he worked at the facility for 7 years. He said on Friday night the Resident #1 was fine but complained of being nauseated. He said Resident #1 was a two person assist and most of the time when CNA A went into the room, he was with her. He said Resident #1 was sick all-night Saturday, 9/30/23 they told the nurse several times. He said about 5:30 a.m. when then did the last round Resident #1 seemed dead. They could not get her to open her eyes, they changed her and told the nurse. She had her oxygen on at that time. During an interview on 10/5/23 at 5:53 a.m. CNA A said they had informed LVN C several times on Saturday night Resident #1was sick. She said she never saw her go into her room. She said Resident #1 was wet each time they went into change her and she had her oxygen on. She said what they did to Resident #1 was not right. They knew she was sick all weekend and did nothing. A statement written by CNA A dated 10/5/23 indicated on Friday 9/29/23 Resident #1 was responsive and said she was nauseated. On Saturday, 9/30/23 Resident #1 was responsive at 6:00 p.m. and complaining about being nauseated. She started throwing up around 8-8:30 p.m. as the night progressed, she started to get worse. She said we, ( Me and CNA B) told LVN C she needed to go to the hospital. CNA A said LVN C said she was going to give her some more anti-nausea pills. She said around 5:30 a.m. Resident #1 was incoherent and they ( she and CNA B) could not wake her up. She said they told LVN C. she said LVN C went to check on Resident #1 one time when she was throwing up and did not go back to check on her during the night. During an interview on 10/5/23 at 5:57 a.m. CNA B said when they went in to change Resident #1 her brief was wet. He said she was different and sick for the last couple of nights. He said they all thought it was because of the new medications they had given her because she was not like that before. He said they told LVN A several times that night and that morning the resident was sick. He said at 5:30 a.m. they told LVN C, Resident #1 was not responsive. He said he never saw her move to go toward her room. During an interview on 10/5/23 at 6:10 a.m. LVN C said she had held Residents #1'sTramadol on the night of 10/1/23 because she was throwing up and she felt it had something to do with the medications. She had not called the physician with any of her concerns. During an interview on 10/5/23 at 7:00 a.m. LVN E said on 10/1/23 when the night nurse ( LVN C) left, she told her Resident #1 had been throwing up. She said LVN E said she had looked in on Resident #1 and she was okay. She said she did not give her any medications that morning before she left for the hospital, the medication aide gave the medications. The medication aide did not arrive until 8:00 a.m. LVN E said Resident #1 could have been having a reaction to the medications. She said the nurses were the ones that wrote the notes in the chart about no adverse reactions to the medications. She thought it was somewhere on the nurse MAR that they put that information. During an interview with on 10/5/23 at 8:30 a.m. MA I said she did not write anything in the cart about adverse reactions to medications, that was the nurses that did that. She said Resident #1 had some new medications and she gave them as prescribed. She said Resident #1 always took her medication without any problems. MA I said she did not know anything about Resident #1 being sick. During an interview on 10/11/23 at 2:55 p.m. the DON said it was the facility policy that nurses give the initial dose of new medications to residents. She said after that the MAs give the medication, but the nurses are to check for adverse reactions to the medications. She said it was her policy that the nurses notify her of any change in condition before they send someone out to the hospital. She said if the family request the nurses send them out and call her after. She said she had a procedure written down that she gave to nurses on hire. During an interview on 10/11/23 the Medical Director of the facility said he could not talk to me about patient information. He was not familiar with Resident #1 right off hand, or why she was taken to the hospital. He said did not