Every finding on record at The Columns Rehabilitation and Healthcare Center

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 93. Findings: Review of an undated facility policy on 04/21/2026 at 8:46 a.m. titled, Sanitation Inspection revealed the following in part.It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Review of an undated facility policy on 04/20/2026 at 2:50 p.m. titled, Date Marking for Food Safety revealed the following part .The facility adheres to a date marking system to ensure the safety of ready -to-eat, time/temperature control for safety of food. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 5. The discard day or date may not extend the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. 6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. 7. The Dietary Manager shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. Observation on 04/20/2026 at 8:32 a.m. of the facility kitchen accompanied by S3 DM revealed the following: Small Refrigerator:One gallon of remoulade sauce with an expiration date of 09/25/2025. Dry Pantry Storage:One gallon of apple cedar vinegar with expiration date of 03/26/2026.One gallon of red vinegar with expiration date of 05/12/2023.One undated, opened container of grape jelly jam.One undated, opened bag of butterscotch powdered pudding.One undated, opened bag of brown gravy. Walk-In Refrigerator:One bottle of lime juice with expiration date of 11/2025. Main Freezer:One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of chicken strips (over 10 individual strips).One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of dark chicken strips (over 40 individual strips).One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of okra (over 100 pieces of okra).One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of biscuits (over 50 individual biscuits). At the time of observation, S3 DM confirmed all of the above findings. S3 DM revealed that all dietary staff are aware of how to correctly label/store opened food items and to discard any expired food items in the kitchen. S3 DM confirmed the above listed items were expired, opened, unsealed, and/or undated and should have been handled or disposed of properly.

Based on record reviews and interview, the facility failed to ensure residents receiving a psychotropic medications had a Gradual Dose Reduction (GDR) completed for 1 resident (Resident #26) of 5 (#8, #13, #26, #40, #87) residents reviewed for unnecessary medications.Findings:Review of the facility's undated policy titled, Gradual Dose Reduction of Psychotropic Drugs, revealed in part, Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs. Review of Resident #26's medical records revealed an admit date of 06/16/2025 with the following diagnoses, including in part: Parkinson's Disease With Dyskinesia, With Fluctuations, Chronic Obstructive Pulmonary Disease, Unspecified, Alzheimer's Disease, Delusional Disorders, Depression, and Anxiety Disorder. Review of Resident #26's Physician's Orders revealed in part the following orders:Haloperidol Oral Tablet 5 MG (milligrams), Give 1 tablet by mouth at bedtime related to Alzheimer's Disease with a start date of 01/22/2026 Lorazepam Oral Tablet 0.5 MG, Give 1 tablet by mouth three times a day related to Anxiety Disorder with a start date of 11/24/2025Quetiapine Fumarate Oral Tablet 50 MG, Give 1 tablet by mouth every morning and at bedtime related to Unspecified Dementia with a start date of 06/16/2025Sertraline Oral Tablet 50 MG, Give 1 tablet by mouth one time a day for depression related to Depression with a start date of 09/18/2025 Review of Resident #26's most recent GDR dated 01/28/2026 failed to reveal Haloperidol Oral Tablet 5 MG, Lorazepam Oral Tablet 0.5 MG, Quetiapine Fumarate Oral Tablet 50 MG or Sertraline Oral Tablet 50 MG, were reviewed for an attempted GDR and a rationale was provided for continuing psychoactive medication at current dose by the Physician/Nurse Practitioner. The GDR also requested a valid Diagnosis (Dx) for Haloperidol Oral Tablet 5 MG and Quetiapine Fumarate Oral Tablet 50 MG which was left blank as well. In an interview on 04/22/2026 at 12:30 p.m., S2 DON (Director of Nursing) acknowledged Resident #26's GDR dated 01/28/2026 was not completed and signed by a physician.

Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #96) of 1 resident reviewed for transfer/discharge. The total sample size was 30.Findings:Review of the facility's undated policy titled, Transfer and Discharge (Including AMA) read in part. Policy Explanation and Compliance Guidelines: 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and a manner in which they can understand. The notice will include all of the following at the time it is provided: h. the name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.Review of Resident #96's medical record revealed an admission date of 02/04/2026 and a discharge date of 03/04/2026. Resident #96 had diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #96's Discharge-Return Not Anticipated MDS with an ARD of 03/04/2026 revealed in part.Type of discharge: unplanned. Review of the facility's March 2026 Emergency Transfer Log revealed a list of only hospitalization transfers and Resident #96's discharge was not listed.In an interview on 04/22/2026 at 2:51 p.m., S7 SSD revealed she was only aware to report hospitalizations to the Louisiana Ombudsman Program using the Emergency Transfer Log and had not reported any discharges from the facility to the Louisiana Ombudsman Program. S7 SSD confirmed she did not report Resident #96's discharge on [DATE] to the Louisiana Ombudsman Program.

Based on observations, record reviews, and interviews the facility failed to provide care and services that meet professional standards of quality, by failing to accurately assess 1 resident (Resident #87). The total sample size was 30 residents.Findings:Review of Resident #87's medical record revealed an admission date of 08/22/2025 with diagnoses that included in part. Alzheimer's Disease with Late Onset, Atrial Fibrillation, and Cognitive Communication Deficit. Review of Resident #87's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/22/2026 revealed in part a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. Review of Resident #87's physician orders revealed in part.Eliquis (an anticoagulant or blood thinner) Oral Tablet 2.5 MG (milligrams) Give 1 tablet by mouth every morning and at bedtime related to Unspecified Atrial Fibrillation with a start date of 08/22/2025.Monitor side effects of anticoagulant therapy.0 - .6 - Abnormal bruising, with a start date of 08/22/2025.An additional order for Weekly Skin Inspections was dated 04/01/2026. Review of Resident #87's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2026 revealed in part.Resident #87 is receiving Eliquis as ordered. Under the order to monitor side effects of anticoagulant therapy, there was no documentation of Resident #87's bruising. Resident #87's weekly skin assessments dated 04/03/2026, 04/10/2026, and 04/17/2026 also revealed no documentation of bruising. Review of Resident #87's Weekly Skin Check assessment report dated 04/17/2026 revealed no documented bruising. Review of Resident #87's current Care Plan revealed medication interventions with an initiation date of 01/07/2026, that included monitoring for bruising. In an interview and observation of Resident #87 on 04/22/2026 at 9:25 a.m., S11 LPN, revealed an observation of extensive bruising to Resident #87's left hand and fingers as well as to the right side of her neck. S11 LPN denied receiving any reports of an incident which may have contributed to bruising. S11 LPN stated the wound care or treatment nurse performs a weekly skin inspection on Resident #87. In an interview with S12 TX RN on 04/22/2025 at 12:45 p.m., S12 TX RN revealed she was familiar with Resident #87 and does perform treatments and skin assessments on Resident #87. S12 TX RN denied knowledge of extensive bruising. Observation of Resident #87 with S2 DON on 04/22/2026 at 12:45 p.m., S2 DON revealed Resident #87 did have significant bruising on her left hand and right side of her neck. S2 DON stated the bruises were in various stages of healing, which indicated some new and some older bruising. In an interview with S2 DON on 04/22/2026 at 12:50 p.m., S2 DON revealed there was no documentation in Resident #87's electronic health record of the bruising that was revealed to be on Resident #87 during the observation with this surveyor. S2 DON confirmed neither the hall nurses nor treatment nurses had been accurately documenting on the condition of the resident's skin as ordered.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. The sample size was 30. The facility failed to ensure: Enhance Barrier Precautions (EBP) were implemented and utilized for Resident #10; andProper hand hygiene and gloving were performed throughout Resident #10's wound care treatment.Findings: Review of an undated facility policy on 04/21/2026 at 4:22 p.m. titled, Clean Dressing Change revealed the following in part .It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify the type of dressing and frequency of changes. 9. Loosen the tape and remove the exiting dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered. Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Review of an undated facility policy on 04/21/2026 at 9:26 a.m. titled, Enhanced Barrier Precautions revealed the following in part .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. 2. Initiation of Enhanced Barrier Precautions: b. an order for Enhanced Barrier Precautions will be obtained for residents with any of the following: i. wounds (ex. chronic wounds such as pressure ulcers). 4. High contact resident care activities include: d. providing hygiene, f. changing briefs or assisting with toileting, h. wound care: any skin opening requiring a dressing. Review of Resident #10's medical record revealed an admission date of 01/26/2026 with diagnoses, which included Alzheimer's Disease, Mild Protein-Calorie Malnutrition, Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, and Adult Failure to Thrive. Review of Resident #10's admission MDS with an ARD of 02/01/2026 revealed a BIMS score of 11, which indicated moderate cognitive impairment. Resident #10 required substantial/maximum assistance with toileting hygiene and was dependent on staff with personal hygiene and toilet transfers. Resident #10 had multiple pressure injuries ranging from stage 1- stage 3, required pressure injury care, and applications of ointments/medications/nonsurgical dressings to areas of the body other than to the feet. Resident #10 also required hospice care services. Review of Resident #10's current physician's orders revealed the following in part .-Cleanse an unstageable pressure ulcer to the coccyx with normal saline or wound cleanser, pat dry. Apply santyl to the wound bed, cover with calcium alginate, and cover with a dry dressing. Perform daily or as needed for soiled or missing dressing every day shift for wound healing. (Start date: 04/01/2026).-Admit to hospice with a diagnosis of Alzheimer's (Order Date: 01/26/2026). Further review of Resident #10's current physician's orders revealed no orders for EBP related to her unstageable coccyx pressure ulcer. Review of Resident #10's skin issues assessment for the following dates revealed .-03/26/2026: Location: coccyx; Skin issue: pressure ulcer/injury; Pressure ulcer staging: unstageable pressure ulcer/injury; Acquired: present on admission; Exudate amount: moderate; and Exudate type: serosanguineous- mixture of serous and sanguineous fluid, typically, pale, red, and watery. -04/09/2026: Location: coccyx; Skin issue: pressure ulcer/injury; Pressure ulcer staging: unstageable pressure ulcer/injury; Unstageable ulcer due to: slough and/or eschar; Acquired: present on admission; Exudate amount: moderate; and Exudate type: serosanguineous- mixture of serous and sanguineous fluid, typically, pale, red, and watery. -04/16/2026: Location: coccyx; Skin issue: pressure ulcer/injury; Pressure ulcer staging: unstageable pressure ulcer/injury; Unstageable ulcer due to: slough and/or eschar; Acquired: present on admission; Exudate amount: faint; and Exudate type: serosanguineous- mixture of serous and sanguineous fluid, typically, pale, red, and watery. Review of Resident #10's current care plan revealed the following in part . (Date Initiated: 02/02/2026) Focus: I have the following pressure ulcers: 01/26/2026 stage 3 to coccyx (restaged to unstageable pressure ulcer on 02/12/2026). Interventions: Wound care provided as ordered. Further review of Resident #10's current care plan revealed no care plan for EBP related to her unstageable coccyx pressure ulcer. Review of a facility staff in-service conducted on 03/04/2026 revealed the staff were educated on signage for residents, which included EBP symbols and signage. EBP posted signage would be identified by a symbol of a pair of gloves and a check mark. S5 CNA was documented as present during the in-service. Treatment observation on 04/21/2026 at 8:55 a.m. revealed S4 TX RN perform Resident #10's unstageable coccyx pressure injury care, with S10 CNA, who assisted with brief care and turning/repositioning of Resident #10. Observed S4 TX RN perform hand hygiene and apply gloves prior to beginning wound care. S4 TX RN and S10 CNA (both with only gloves on) repositioned/turned Resident #10 and exposed the resident by removal of her incontinence brief. S4 TX RN removed the dirty wound dressing and described the pressure injury drainage as moderate serosanguineous drainage, with the wound bed as having slough and eschar. S4 TX RN disposed of the dirty wound dressing and then, without hand hygiene or glove change, touched the clean supplies and cleaned the coccyx wound bed. S4 TX RN began to put her same contaminated/dirty gloved finger in a cup of santyl and applied the ointment to Resident #10's coccyx wound bed, with her pointer finger. With the same contaminated/dirty gloves, S4 TX RN applied calcium alginate and covered the coccyx wound bed with a dry dressing. S4 TX RN completed the treatment at 9:08 a.m. and disposed of all supplies in a red biohazard bag. S4 TX RN performed hand hygiene after disposal of biohazard waste. At the time of the treatment observation, S4 TX RN revealed Resident #10 admitted to the facility with multiple skin issues/pressure ulcers and required hospice services. S4 TX RN described Resident #10's coccyx pressure ulcer as actively draining and had deteriorated into an unstageable due to eschar and slough present in the wound bed. S4 TX RN revealed the unstageable pressure ulcer was very slow to heal due to the resident's end of life disease process. In an interview on 04/21/2026 at 9:08 a.m., S4 TX RN confirmed all the above findings during the treatment observation. S4 TX RN revealed she did not know why she only completed hand hygiene and a glove change prior to starting the treatment. S4 TX RN confirmed she should have performed hand hygiene and glove changes between each task of the treatment, but did not. S4 TX RN revealed Resident #10 did not require EBP procedures and did not know why the resident didn't require EBP. In an interview and record review on 04/21/2026 at 9:11 a.m., S2 DON/IP revealed she expected S4 TX RN to perform hand hygiene and glove changes between each task of Resident #10's wound care treatment. In a record review, at the time of interview, S2 DON/IP revealed Resident #10 did not have orders for EBP procedures. S2 DON/IP revealed she was filling in as the facility Infection Preventionist and stated, I don't know why Resident #10's is not on EBP. S2 DON/IP revealed that as the facility DON/IP, she should be aware if Resident #10's unstageable coccyx pressure ulcer required EBP procedures. S2 DON/IP confirmed Resident #10 should have had EBP procedures due to the resident having a slow to heal, draining, unstageable coccyx pressure ulcer, and required hospice services, but did not. In an interview on 04/22/2026 at 12:19 p.m., S5 CNA revealed she was assigned to Resident #10 and required total care with most ADLs (Activities of Daily Living). S5 CNA revealed she provided incontinent care, a bath, repositioning/turning, and dressed the resident this morning while only wearing gloves. S5 CNA revealed Resident #10 did not require EBP procedures. Observation on 04/22/2026 at 12:25 p.m. revealed EBP signage posted on the doorframe of Resident #10's room. In an interview on 04/22/2026 at 12:31 p.m., S6 LPN revealed she was assigned to Resident #10 and aware of the resident's skin issues, including the coccyx pressure ulcer. S6 LPN revealed the resident admitted to the facility with this pressure ulcer, it had since deteriorated into an unstageable due to her disease process and worsening condition. S6 LPN described the coccyx pressure ulcer as slow to heal due to the resident's disease progression. S6 LPN revealed Resident #10 had a history of receiving antibiotic therapies due to an infection of the coccyx wound and had recently completed the antibiotic cycle. Note: After surveyor notification of all of the above issues in Resident #10's pressure injury investigation, the facility updated her record to reflect the implementation of EBP procedures on 04/21/2026.

Based on record review and interview the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner for falls. The facility failed to provide documentation of evidence of its ongoing facility QAPI program. This deficient practice had the potential to affect 85 residents residing in the facility. Findings:A facility policy titled Quality Assurance and Performance Improvement (QAPI), with a revision date of 04/28/2025 revealed in part.It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.Definitions: Quality Assurances and Performance Improvement (QAPI) refers to the coordinated application of two mutually reinforcing aspects of a quality management system: (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes, while involving residents and families in practical and creative problem solving.Review of the facility's incident log for 09/2025, 10/2025 and 11/2025 revealed the following:Fall incidents for 09/01/2025 to 09/30/2025 revealed a total of 15 falls with 3 major injures.Fall incidents for 10/01/2025 to 10/31/2025 revealed a total of 20 falls with 3 injuries.Fall incidents for 11/01/20245 to 11/30/2025 revealed a total of 14 falls with 4 injuries.Review of a facility form titled Quality Assessment and Improvement Committee Summary revealed there was no QAPI program developed, implemented, and/or maintained in an effective and comprehensive manner for falls. Interview on 12/03/2025 at 1:55 p.m. with S1 Administrator and S2 DON confirmed the facility had no evidence of an effective QAPI for falls. S1 Administrator stated the facility's QAPI program was not up to standard.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Nursing carts were free of loose pills for 1 (Cart A) of 2 (Cart A and Cart B) carts reviewed, and 2. Nursing carts were free of expired supplies for 1 (Cart B) of 2 (Cart A and Cart B) carts reviewed. Findings: Review of the facility's policy entitled Storage of Medication Requiring Refrigeration revised on 09/01/2024 revealed, in part .the facility must provide safe and effective storage of all drugs and biologicals consistent with professional standards of practice. Staff should remove any expired medications from active stock and discard according to facility policy. Interview with S19 CQI on 05/14/2025 at 12:23 p.m. confirmed the facility's policy entitled Storage of Medication Requiring Refrigeration was used for all medications in the facility, not just refrigerated medications. Observation of Cart A on 05/13/2025 at 1:45 p.m., with oversight from S9 LPN, revealed 2 unidentified and loose tablets in the bottom of the 2nd drawer of the cart. S9 LPN confirmed there were 2 unidentified and loose tablets in the 2nd drawer of Cart A, that should not have been. Observation of Cart B on 05/14/2025 at 1:00 p.m., with oversight from S18 Treatment Nurse, revealed 17 Lubricating Jelly 3 gram packages with an expiration date of 03/2019, 8 Skin Protectant Cream with Lanolin 0.18 ounce packages with an expiration date of 09/2024, 1 Lubricating Jelly 3 gram package with an expiration date of 04/12/2022, and 1 Skin Protectant Ointment 5 gram package with an expiration date of 05/2024. S18 Treatment Nurse confirmed the expired supplies were in Cart B, and should not have been.

Based on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 1 (Resident #51) of 26 sampled residents. Findings: On 05/14/2025, review of facility policy titled, Answering Call Lights, with effective date of 06/01/2023 and revision Date of 9/28/2025, revealed in part . Purpose: Call lights are to serve as notice to the staff that the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident . Process: Place call light within reach of the resident before leaving the room and anticipate other needs of the resident . Resident #51 Review of Resident #51's electronic medical record revealed an admitted [DATE] with diagnosis that included: Neurocognitive Disorder with Lewy Bodies, Major Depressive Disorder, Altered Mental Status, Generalized Anxiety Disorder, Aphasia, Cognitive Communication Deficit, Hallucinations, unspecified, unsteadiness on feet, and history of repeated falls. Review of Resident # 51's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 03/19/2025, revealed a BIMS (Brief Interview for Mental Status) Score of 10, indicating moderate cognitive impairment. Resident #51 required supervision/touching assistance for transfers and sit to stand positioning. Review of Resident #51's Care Plan revealed in part . Resident #51 had a self- care deficit r/t (related to) Neurocognitive d/o (disorder) with Lewy Bodies, muscle wasting and atrophy. Interventions included in part . limited assistance by (1) staff to move between surfaces. Resident #51 was at high risk for falls. Interventions included in part . Resident #51 would have call light placed within reach, encouraged to use call light for assistance as needed, receive prompt response to all requests for assistance, remain in a safe environment with a working and reachable call light . On 05/12/2025 at 10:20 a.m. Observation revealed Resident #51 lying in bed. Call light was clipped to resident privacy curtain located at the foot of the bed. Resident #51 could not reach the call light. On 05/12/2025 at 11:20 a.m. Observation revealed Resident #51 loudly calling out Help from down the hall. On 05/13/2025 at 09:01 a.m. Observation revealed Resident #51 sitting up in wheelchair in room. Call light was clipped to privacy curtain. Call light was not within reach for Resident #51. On 05/13/2025 at 2:20 p.m. observation/interview revealed Resident #51 lying across her bed, awake, alert, and confused. Resident #51 pointed in the direction of the call light system when asked how she requested help or assistance. Call light was clipped to privacy curtain located at the foot of the bed. Call light was not within reach for Resident #51. On 05/13/2025 2:55 p.m. S6 LPN accompanied surveyor to Resident #51's room. S6 LPN confirmed call light was not accessible to resident and should have been. On 05/14/2025 at 12:43 p.m. above findings were discussed with S2 DON. S2 DON acknowledged Resident #51 should have had call light within her reach while in room. S2 DON confirmed staff should be monitoring call light locations on routine rounds.

Based on record review and interview, the facility failed to inform each resident of the charges for services for which the residents may be responsible for paying for 2 (#45 and #70) of 2 (#45 and #70) sampled residents who received Advanced Beneficiary Notices of Non-Coverage (ABN). Findings: Review of the ABN notices (Form CMS-10055) signed by Resident #45 on 02/17/2025 and Resident #70 on 03/19/2025 revealed the estimated cost for continuing daily skilled nursing care was not completed but left blank. In an interview on 05/14/2025 at 12:10 p.m., S5 Accounts Manager confirmed she was responsible for completing the ABN forms and having them signed by the resident or representative. During a review of the Form CMS-10055 for Residents #45 and #70 at that time, S5 Accounts Manager confirmed the estimate of the cost of services amount per day was not completed. S5 Accounts Manager stated she would have to get that information from the Corporate Office and only does so if the resident or resident representative specifically requests it. S5 Accounts Manager confirmed she did not obtain the cost information from Corporate Office for Resident #45 or Resident #70. In an interview on 05/14/2025 at 12:15 p.m., S1 Administrator confirmed the costs for the services should be listed on the ABN form and was not.

Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a dose reduction for 2 (#37 and #51) of 5 (#24, #37, #45, #50, and #51) residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction. Findings: Review of the facility policy on 05/13/2025 at 11:29 a.m., titled Gradual Dose Reduction of Psychotropic Drugs with a revision date of 09/01/2024 revealed in part .Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 6. For any individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distress behavior. Resident #37 Review of Resident #37's clinical record revealed an admitted [DATE] with diagnoses that included in part., Aphasia, Major Depressive Disorder, Generalized Anxiety Disorder, and Anxiety Disorder. Review of Resident #37's Quarterly MDS with an ARD of 05/17/2025 revealed a BIMS score of 15, indicating intact cognition. Resident #37 received an antianxiety and antidepressant medication. Review of Resident #37's 05/2025 physician's orders revealed the following: Fluoxetine Hydrochloride (HCl) capsule 20 mg (milligrams) related to Major Depressive Disorder (11/12/2022) Alprazolam tablet 0.25mg related to Anxiety Disorder (11/11/2022) Review of the Pharmaceutical Consultant Report that was signed and dated by S13 ADON and S14 MD on 01/16/2025. The pharmacy consultant requested a gradual dose reduction for Alprazolam tablet 0.25mg and Fluoxetine HCl capsule 20mg. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a hand written valid clinical rationale as to why the reduction is not desired at this time. S14 MD documented NO for if a dose reduction is appropriate. S14 MD failed to provide a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated. 52255 Resident #51 Review of Resident #51's electronic health record revealed an admitted [DATE] with diagnosis that included: Neurocognitive Disorder with Lewy Bodies, Major Depressive Disorder, Altered Mental Status, Generalized Anxiety Disorder, Aphasia, Cognitive Communication Deficit, Hallucinations, unspecified, unsteadiness on feet, history of repeated falls. Review of Resident # 51's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 03/19/2025, revealed a BIMS (Brief Interview for Mental Status) Score of 10, indicating moderate cognitive impairment. Resident #51 received antipsychotic and antidepressant medication. Review of Resident #51's 05/2025 physician's orders revealed the following: Olanzapine oral tablet 5mg (milligram) one tablet by mouth daily for visual hallucinations related to Neurocognitive Disorder with Lewy Bodies (04/04/2023) Sertraline HCl tablet Give 75mg by mouth one time a day for Depression related to Major Depressive Disorder (03/15/2023) Trazadone HCl tablet 50mg Give 0.5 tablet by mouth at bedtime for dementia related to Major Depressive Disorder, Recurrent; Mild Insomnia, Unspecified (08/27/2024) Review of Resident #51's Pharmaceutical Consultant Report that was signed and dated by S13 ADON and S14 MD on 01/16/2025. The pharmacy consultant requested a gradual dose reduction for Olanzapine oral tablet 5mg (milligram), Sertraline HCl tablet 75mg, and Trazadone HCl tablet 50mg. The report read in part . Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a hand written valid clinical rationale as to why the reduction is not desired at this time. S14 MD documented NO for if a dose reduction is appropriate. S14 MD failed to provide a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated. On 05/14/25 at 11:30 a.m. interview conducted with S2 DON. Pharmaceutical Consultant Reports for Resident #37 and Resident #51 reviewed with S2 DON. S2 DON confirmed S14 MD should have provided a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated for Resident #37 and Resident #51, and did not.

Based on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #45) of 26 sampled residents. Findings: Review of Resident #45's medical record revealed an admitted [DATE] with diagnoses including, in part .Muscle Wasting and Atrophy, Unspecified Protein-Calorie Malnutrition, and Dementia. Review of Resident #45's Quarterly MDS with an ARD of 02/17/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #45 required supervision or touching assistance while eating. Resident #45 had significant weight loss and was not on a prescribed weight-loss regimen. Review of Resident #45's current comprehensive care plan revealed a history of unplanned/unexpected weight loss related to recent illness and hospitalization , initiated on 03/16/2023 and revised on 08/27/2023 and 11/21/2024. Interventions included, in part .monitor and record my food intake at each meal. Review of Resident #45's Nutrition - Meal Intake of Food & Drink task for 02/2025, 03/2025, 04/2025, and 05/01/2025 through 05/13/2025, revealed meal intake had not been documented for 31 meals in 02/2025, 37 meals in 03/2025, 40 meals in 04/2025, and 13 meals in 05/2025. Interview with S9 LPN on 05/13/2025 at 8:36 a.m., revealed CNAs are required to input the meal intake for residents after each meal. Interview with S17 LPN on 05/13/2025 at 10:37 a.m., revealed CNAs are required to input the meal intake for residents after each meal. Interview with S2 DON on 05/13/2025 at 11:35 a.m. confirmed Resident #45's meal intake should be documented for every meal. S2 DON confirmed Resident #45's care plan intervention of monitoring and recording food intake at each meal had not been consistently implemented during 02/2025, 03/2025, 04/2025, and 05/01/2025 through 05/13/2025, but should have been.

Based on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan was revised after a quarterly assessment for 1 (Resident #45) of 26 sampled residents. Findings: Review of Resident #45's medical record revealed an admitted [DATE] with diagnoses including, in part .Muscle Wasting and Atrophy, Difficulty in Walking, Unsteadiness on Feet, Muscle Weakness, and Dementia. Review of Resident #45's Quarterly MDS with an ARD of 02/17/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #45 used a manual wheelchair and had limited range of motion to his lower extremities. He was dependent for ambulation. Review of Resident #45's current care plan revealed the resident had limited physical mobility related to generalized weakness, initiated on 10/07/2022. Interventions included, in part .the resident walks independently, initiated on 10/07/2022 and revised on 02/17/2023. Interview with S2 DON on 05/14/2025 at 11:50 a.m. revealed Resident #45 could not walk independently. S2 DON confirmed Resident #45's current care plan indicated he walked independently, but should not. S2 DON confirmed Resident #45's care plan had not been revised after his Quarterly MDS with ARD of 02/17/2025, but should have been.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (Resident #24) of 26 sampled residents. Findings: Review of the facility's policy entitled, Nail Care dated 06/01/2023 revealed in part .nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath. Review of Resident #24's medical record revealed an admitted [DATE] with diagnoses which included in part Diabetes Mellitus and Morbid Obesity. Review of Resident #24's Annual MDS with ARD of 04/16/2025 revealed in part .a BIMS score of 15, which indicated intact cognition. Resident #24 was dependent for bathing and required substantial/maximal assistance with personal hygiene. Review of Resident #24's current physician's orders revealed, in part .RN was to trim toe nails every month, dated 05/06/2024. Review of Resident #24's care plan revealed in part .the resident was dependent for meeting his physical needs initiated on 05/06/2024. Interventions included assisting the resident with ADLs. Further review revealed Resident #24 was unable to perform ADLs due to polyosteoarthritis and lower muscle wasting. Review of Resident #24's 04/2025 TAR revealed in part .his toe nails were last trimmed on 04/02/2025 and no documentation of nail care for 05/2025. Observation of Resident #24 on 05/12/2025 at 10:13 a.m. revealed long, thickened, yellow, jagged toenails of various lengths to his feet. Resident #24 stated it had been a month or more since his toenails were trimmed, and he wanted them to be trimmed. Interview with S18 Treatment Nurse on 05/14/2025 at 10:50 a.m. regarding Resident #24's toe nails revealed she had tried to trim them a little bit previously. S18 Treatment Nurse confirmed she was unable to trim Resident #24's toe nails as ordered. S18 Treatment Nurse confirmed she did not perform nail care as ordered for Resident #24, but should have. Interview with S2 DON on 05/14/2025 at 11:56 a.m. confirmed Resident #24 should have had routine nail care as ordered, but had not.

Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for a resident with Diabetes. The facility failed to schedule and complete podiatry appointments for toenail care and trimming for 1 (Resident #24) of 3 (Resident #17, Resident #24, and Resident #78) residents sampled for Activities of Daily Living (ADLs). Findings: Review of the facility's policy entitled, Nail Care dated 06/01/2023 revealed in part .refer residents whose toenails are too thick or difficult to cut to a Podiatrist. It is recommended a Podiatrist provides foot care for residents with Diabetes. Review of Resident #24's medical record revealed an admitted [DATE] with diagnoses which included in part Diabetes Mellitus. Review of Resident #24's Annual MDS with ARD of 04/16/2025 revealed in part .a BIMS score of 15, which indicated intact cognition. Resident #24 was dependent for bathing and required substantial/maximal assistance with personal hygiene. Review of Resident #24's current physician's orders revealed in part .may consult specialist of choice, dated 05/06/2024. Review of Resident #24's care plan revealed in part .I have Diabetes Mellitus, initiated on 05/06/2024. Review of Resident #24's 04/2025 TAR revealed in part . his toe nails were last trimmed on 04/02/2025 and no documentation of nail care for 05/2025. Further review of Resident #24's medical record revealed no documentation of a Podiatry referral nor nail care provided by a Podiatrist. Observation of Resident #24 on 05/12/2025 at 10:13 a.m. revealed long, thickened, yellow, jagged toenails of various lengths to his feet. Resident #24 stated it had been a month or more since his toenails were trimmed, and he wanted them to be trimmed. Resident #24 stated he had no appointments with a Podiatrist, but would like to be consulted by Podiatry. Interview with S18 Treatment Nurse on 05/14/2025 at 10:50 a.m. regarding Resident #24's toe nails revealed she had tried to trim them a little bit previously. S18 Treatment Nurse stated that the facility's nail care tools were ineffective due to the thickness of Resident #24's toe nails. S18 Treatment Nurse confirmed Resident #24 needed a Podiatry referral to provide effective nail care, but had not had one. Interview with S2 DON on 05/14/2025 at 11:56 a.m. confirmed Resident #24 needed a Podiatry referral to perform effective nail care, but had not had one.

F692 Based on interview and record review the Facility failed to ensure that a Resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable weight range for 1 (#69 ) of 3 (#39, #45, #69) sampled Residents reviewed for nutrition. Total sample size 26. The facility failed to ensure Resident #69 received ordered nutritional supplements with meals, assistance or encouragement with eating, and accurate documentation of meal intake. Findings: Review of Resident #69's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Aphasia, Alzheimer's disease, Depressive Disorder, Cognitive Communication Deficit, Vitamin B12 Deficiency, and Dementia. Review of Resident #69's Quarterly MDS, with ARD of 04/02/2025, revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #69 was independent with eating. Review of Resident #69's current care plan, revealed in part .Resident #69 has a potential for a nutritional problem. Interventions included in part . Monitor/ document/ report PRN if I exhibit signs and symptoms of dysphagia, pocketing, choking, coughing, drooling, holding food in mouth, or refusing to eat. Resident #69 has unplanned/unexpected weight loss r/t poor food intake. Interventions included in part . Monitor and record my food intake at each meal; Offer my supplements as ordered. Resident #69 has an ADL self-care performance deficit r/t dementia and generalized muscle weakness. Interventions included in part . Eating: I am independent with set up assist. Review of Resident #69's weights revealed the following which represented a significant weight loss: 12/9/2024 = 136.4 pounds 1/6/2025 = 136.0 pounds 2/10/2025 = 137.5 pounds (14.3 pound/10.2% weight loss in 3 months) 3/7/2025 = 136.6 pounds 4/10/2025 = 131.2 pounds 5/9/2025 = 123.2 pounds (8 pound/ -6.10 % weight loss in 1 month) Review of Resident # 69's medical record revealed Resident #69 was weighed monthly until triggered for weight loss. Resident #69 is currently weighed weekly. Review of Health Status Note dated on 05/08/2025, revealed in part .Speech therapy evaluated Resident #69 with new recommendation for mighty shakes. Review of progress note titled Weight Change dated 05/09/2025, revealed in part . Resident #69 assessed by Speech Therapy regarding difficulty swallowing. Resident #69's weight assessed due to decreased appetite and meal intake. Speech therapist recommended mighty shakes with meals. Current weight 123.2lbs, 8lbs weight loss in 30 days. Review of Physician Orders dated on 05/09/2025, revealed in part .Mighty shakes or Magic cup with meals three times a day. Review of Dietician Progress note dated 05/11/2025, revealed in part . Trigger for significant weight loss noted. Current weight 123.2 pounds (8 pound loss in one month). Mighty Shakes added three times a day with meals and Megace added for appetite on 05/10. Continue to monitor. Lunch observation on 05/12/2025 at 12:25 p.m., revealed in part .Resident #69 sitting in the dining room. Observed Resident #69 not eating. Encouragement or assistance not provided by staff. Observation of the tray revealed entree untouched and no mighty shake for lunch. Review of meal intake report dated 05/12/2025 at 01:02 p.m. revealed in part . S11 CNA documented intake of 76-100 % for lunch. Breakfast observation on 05/13/2025 at 09:10 a.m., revealed in part .Resident #69 exiting her room with the therapist. Observation of tray revealed meal set-up was not performed. Observed untouched food on breakfast tray and mighty shake not provided with meal. On 05/13/2025 at 9:20 a.m., observed CNA removing breakfast tray from Resident #69's room. Review of meal intake report dated 05/13/2025 at 12:49 p.m. revealed in part . S15 CNA documented meal intake of 51-75 % for breakfast. Interview on 05/13/2025 at 01:50 p.m. with S15 CNA, revealed Resident #69 does not require feeding assistance but does require meal set up. S15 CNA, revealed meal set up included: Removing cover from plate, opening beverage carton and utensils. S15 CNA confirmed she documented Resident #69's meal intake for breakfast. Lunch observation on 05/13/2025 at 11:47 a.m., revealed in part . Resident #69 sitting in the dining room. Observed Resident #69 not eating. Observation of tray revealed mighty shake served with lunch. Observed resident drink approximately fifty percent of shake. On 05/13/2025 at 12:11 p.m., observed S7 CNA assist resident from dining room back to Resident #69's room. Observed lunch tray which revealed, untouched entree. Encouragement or assistance not offered by staff. Review of meal intake report dated 05/13/2025 at 12:49 p.m. revealed in part . S15 CNA documented meal intake of 76-100 % for lunch. Interview on 5/13/2025 at 01:40 p.m. with S7 CNA, revealed Resident #69 is independent with eating but requires meal set up. S7 CNA, revealed meal set up included: Removing cover from plate, open beverage and utensils. Interview on 05/13/2025 at 02:20 p.m. with S9 LPN, revealed Resident #69 requires cueing and encouragement during meals. S9 LPN confirmed that CNAs are responsible for documenting meal intake and are to notify nurse when a resident does not eat. Interview on 05/13/2025 at 02:32 p.m. with S10 RN clinical support, revealed weights are obtained weekly for residents with significant weight loss. Significant weight loss is reported to Registered Dietician and Physician. S10 RN clinical support confirmed CNAs should have notified nurse of Resident #69's decrease in PO intake. S10 RN clinical support confirmed weight loss was not identified until it became significant. Breakfast observation on 05/14/2025 at 08:36 a.m., revealed in part .breakfast tray on bedside table not set up and food remained untouched. Observation and interview on 05/14/2025 at 09:10 a.m., revealed in part . S11 CNA removing breakfast tray from Resident #69's room. Mighty shake was not observed on breakfast tray. S11 CNA confirmed Resident #69 did not receive a mighty shake with breakfast and should have. Interview on 05/14/2025 at 09:10 a.m. with S12 LPN, confirmed Resident #69 did not receive a mighty shake with breakfast and should have. Interview on 05/14/2025 at 12:30 p.m. with S2 DON, confirmed Resident #69 did not receive nutritional supplements as ordered and should have. S2 DON confirmed inaccurate meal intake documentation. S2 DON confirmed that Resident #69 should have been assisted/ encouraged by staff during meals.

Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regard to portion size to ensure the nutritional adequacy of the meal for all 10 residents who received a puree diet. Findings: In an interview during the initial kitchen tour at 8:50 a.m. on 05/12/2025, S3 Dietary Manager stated the facility had 10 residents being served a puree diet. In an observation on 05/12/2025 at 10:30 a.m., S4 [NAME] used a 2 ounce ladle and put 6 scoops of lima beans into the blender to puree. S4 [NAME] then added 2 scoops of liquid from the lima beans to the blender. S4 [NAME] blended them together and placed them in a pan for the steam table. Review of the recipe for lima beans provided by S3 Dietary Manager revealed for 10 servings, 1 and 1/4 quart (40 ounces) of beans should have been pureed. In an interview on 05/12/2025 at 11:00 a.m., S4 [NAME] confirmed she put 6 scoops of lima beans into the blender with a 2 ounce ladle. In an interview on 05/12/2025 at 11:05 a.m., S3 Dietary Manager confirmed S4 [NAME] did not follow the recipe and did not put enough lima beans in the blender to puree, but should have.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was not open to air while stored in the pantry; and 2. Food serving scoop was not left inside sugar bin in direct contact with resident food items. This deficient practice had the potential to affect 84 residents who received meals served from the kitchen. Findings: An observation on 05/12/2025 at 9:00 a.m. revealed the serving scoop was inside the bulk storage container of sugar lying on top of and in direct contact with the sugar. In an interview at that time, S3 Dietary Manager confirmed the scoop should not be in the sugar bin touching the sugar. An observation on 05/12/2025 at 9:05 a.m. revealed a package of fish breading in the pantry that was open to air. In an interview at that time, S3 Dietary Manager confirmed the fish breading in the pantry was open to air and should not be.

Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 3 (#2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to 1. Ensure Resident #2 was not physically abused by Resident #3; 2. Ensure Resident #3 was not physically abused by Resident #4; and 3. Ensure Resident #4 was not physically abused by Resident #3. Findings: Review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 07/26/2023, revealed in part .The facility's policy strictly prohibits abuse and neglect. This policy is against abuse, neglect, exploitation and misappropriation of resident property including abuse by any other person, including, but not limited to other residents. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately (not-inadvertently or accidentally), not that the individual must have intended to inflict or harm. A cognitively impaired resident that hits another resident, may be considered abusive. Resident #2 Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses that included in part . Acute Pulmonary Edema, Dementia Mild with other behavioral symptoms, Anxiety Disorder, Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease and Bronchitis. Review of Resident #2's Quarterly MDS with an ARD of 02/14/2025, revealed a BIMS score of 15, indicating intact cognition. The MDS revealed Resident #2 was independent with eating, oral hygiene, toileting, dressing, personal hygiene, transfers and ambulation. Resident #3 Review of Resident #3's medical record revealed he was admitted to the facility on [DATE], with diagnoses that included in part .Unsteadiness on Feet, Dementia, Moderate without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Hallucinations Unspecified and Cognitive Communication Deficit. Review of Resident #3's Admission's MDS with an ARD of 02/09/2025, revealed a BIMS score of 99 (resident was unable to complete the interview). The MDS revealed Resident #3 required supervision or touching assistance with eating. Resident #3 required substantial/maximal assistance with toileting, bathing and dressing; partial/moderate assistance with transfers; and used a manual wheelchair for mobility. Review of Resident #3's medical record revealed Resident #3 was sent to theER on [DATE], and was to be transferred to a behavioral hospital due to escalating behavior at the facility. Review of Resident #3's Care Plan with a Target date of 05/12/2025, read in part . 1. I have a behavior problem, (problem onset date of 02/06/2025). I am resistant to ADL care from CNAs at times. I become easily agitated and will be combative and verbally aggressive with staff at times. I will spit out my meds and refuse care. Interventions included in part .Bring me to the nurse's station for closer supervision when I become intrusive. 2. Disrobing in public (problem onset date of 02/06/2025). I get very confused and will believe things that are not true. I do not like being corrected. 03/04/2025 - Intrusive, physically/verbally aggressive. Interventions included in part .I will be removed from the situation and taken to alternate location as needed. I will have interventions as necessary to protect the rights and safety of others. Resident #4 Review of Resident #4's medical record revealed he was admitted to the facility on [DATE], with diagnoses that included in part .Aphasia, Cognitive Communication Deficit, Unspecified Dementia severe without behavioral disturbance, Psychotic Disturbance Mood Disturbance and Bipolar Disorder. Review of Resident #4's Quarterly MDS with an ARD of 02/12/2025, revealed a BIMS score of 5, indicating severe cognitive impairment. The MDS revealed Resident #4 required substantial/maximal assistance with transfer, toileting, bathing and dressing. Resident #4 used a manual wheelchair for mobility. Review of a facility Incident Report dated 03/04/2025 at 5:15 p.m., read in part .Resident #2 yelled up the hall Help, we have a problem down here. Staff went down hall and observed Resident #2 standing in her room, and Resident #3 was in hallway in front of her (Resident #2's) room. Resident #2 stated Resident #3 came in her room, and she asked him to get out. In return, Resident #3 kicked her in her right shin before she could get assistance. Immediate Action Taken: Inspected Resident #2's skin. No redness, bruising, or opened area noted at this time. Resident #2 denies injury or pain at this time. DON notified of situation. Resident #3 immediately removed by another staff member from hallway. Injuries observed at time of incident - No injuries observed. Review of the facility Incident Report dated 03/04/2025, revealed a note dated 03/07/2025 (no time), that read in part .Upon investigation, it was noted that Resident #3 was showing signs of increased agitation in the dining room and was not easily re-directed. Staff then escorted him to his room to be in a lower stimulating environment. Moments later, Resident #2 was calling for assistance. Investigation revealed that Resident #3 had entered Resident #2's room trying to get her snacks. Resident #2 stated that she started yelling at him to get out of her room, when he kicked her in her right lower leg. Resident #2 stated that Resident #3 was backing out of her room when Resident #4 intervened on her behalf. Resident #2 stated Resident #4 hit Resident #3 in the back, and started pulling his (Resident #3's) wheelchair out of her doorway. Meanwhile, Resident #2 called for staff assistance. Resident #4 stated that as soon as he had Resident #3 in the hallway, Resident #3 managed to turn around facing Resident #4, then kicked him (Resident #4) on the right lower leg. Staff immediately deescalated the situation by removing Resident #3 from the area, and by placing him on 1:1 supervision. Interview on 04/09/2025 at 9:46 a.m. with S1 DON, revealed video surveillance captured the following in part . 03/04/2025 at 5:00 p.m. - staff brought Resident #3 into the dining room for meal service. Resident #3 was placed at the back table. Resident #3 immediately unlocked his wheelchair and moved from table to table, attempting to take other residents' belongings. Several residents were calling to someone to move him elsewhere. Staff attempted re-direction. During this time Resident #3 was observed touching what seemed to be everything. He was also seen trying to eat from dirty dishes that were placed in the window. Resident #3 was re-directed again. 03/04/2025 at 5:15 p.m. - S1 CNA removed Resident #3 from the dining room and escorted him to his room. S1 CNA then walked up the hall to tell Resident #3's nurse. 03/04/2025 at 5:16 p.m. - Resident #3 came out of his room and opened Resident #2's room door and entered her room. Resident #3 was seen slowly backing out of Resident #2's room. 03/04/2025 at 5:17 p.m. - Resident #4 came out of his room and hit Resident #3 in his back, and started to pull Resident #3's wheelchair out of Resident #2's doorway. Resident #2 was seen standing in the hallway looking towards the nurse's station calling for assistance. While Resident #4 had a hold of Resident #3's wheelchair, Resident #3 managed to turn his wheelchair around and then kicked Resident #4 on the leg. S1 DON confirmed at that time that Resident #2 and Resident #4 were victims of resident to resident physical abuse by Resident #3, and Resident #3 was a victim of physical abuse by Resident #4 on 03/04/2025. Interview on 04/08/2025 at 1:30 p.m. with Resident #2 revealed about a month ago (03/04/2025), Resident #3 who resided across the hallway from her attempted to enter her room. Resident #2 stated she told Resident #3 no, but he continued to try and enter her room. Resident #2 stated Resident #3 kicked her on the right shin. Resident #2 stated Resident #4 (roommate to Resident #3), came to get Resident #3 out of her room. Resident #2 stated Resident #4 hit Resident #3 on the back, and Resident #3 kicked Resident #4 on the leg. Interview on 04/08/2025 at 12:18 p.m. with Resident #4, revealed he remembered the evening when Resident #3 tried to enter resident #2's room; however, he was unable to remember the date. Resident #4 stated he heard Resident #2 call for help, so he went across the hall to see what was going on. Resident #4 stated Resident #3 was trying to push past Resident #2 to enter he room. Resident #4 stated he went to grab resident #3's wheelchair to get him away from Resident #2, and he hit Resident #3 across his back. Resident #4 revealed Resident #3 then turned in his wheelchair and kicked him on the leg. Telephone interview on 04/09/2025 at 10:23 a.m. with S2 CNA, revealed on 03/04/2025 at 5:00 p.m. Resident #3 was in the dining room in a wheelchair. S2 CNA stated Resident #3 left his table and went to where the dirty dishes were in the kitchen window, and was trying to get food off the dirty plates. S2 CNA stated she re-directed Resident #3 back to his table and he became verbally aggressive calling her the N word. S2 CNA stated Resident #3 left his table again and was messing with other residents in the dining room. S2 CNA stated Resident #3 rolled up to a blind resident and was trying to get something out of his back pack. Another resident intervened, and Resident #3 became verbally aggressive towards that resident. S2 CNA stated she took Resident #3 out of the dining room back to his room, and stopped by the nurse's station and told S3 LPN about Resident #3's behaviors. Telephone interview on 04/09/2025 at 11:41 a.m. with S3 LPN revealed on 03/04/2025 Resident #3 had been upset that day after his Care Plan meeting, because it had been determined Resident #3's still required a pureed diet. S3 LPN stated S2 CNA had reported to her she had to remove Resident #3 from the dining room during the evening meal, because he was being disruptive in the dining room, and messing with other residents. S3 LPN stated Resident #3 had no behaviors at the other meal services that day. S3 LPN stated she told S2 CNA that's fine, I'll check on him in a few minutes. S3 LPN revealed before she could check on Resident #3, he exited his room and tried to enter Resident #2's room and kicked her on the leg. When Resident #4 tried to intervene, he (Resident #4) hit Resident #3 in the back, and in turn Resident #3 kicked Resident #4 on the leg.

Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for the treatment of a skin tear was followed for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 90. Findings: Review of the Facility policy titled: Skin Tears, with an effective date of 04/04/2024 revealed in part . Process: 2 (b). Tropical treatments in accordance with current standards of practice will be provided for residents who have a skin tear. 4. Monitoring b. Licensed nurses will participate in the management of skin tears and medical conditions by following physician orders. Assessment of residents, and reporting changes in condition to the resident's physicians. Review of Resident #3's clinical record revealed an admitted [DATE] with diagnoses which included in part . Alzheimer's Disease with Late Onset, Impulse Disorder Unspecified, Generalized Anxiety, History of Falling and Dementia. Review of Resident #3's Quarterly MDS with an ARD of 09/04/2024 revealed a BIMS score of 99 (indicating interview was unsuccessful), Resident #3 required setup or clean-up assistance with eating. Resident #3 was dependent on staff for oral hygiene, toileting, bathing, dressing and personal hygiene. Review of Resident #3's care plan with a target date of 12/01/2024 revealed in part .I have a skin tear to right lower leg. Interventions that included: if I receive a skin tear, treat per facility policy protocol. Review of Resident #3's Physician's orders revealed: 10/15/2024: Cleanse skin tear to right lower leg with normal saline, pat dry, and apply tegaderm, every 3 days until healed. ? Review of Resident #3's TAR (Treatment Administration Record) revealed in part . Cleanse skin tear to right lower leg with normal saline, pat dry and apply Tegaderm every 3 days until healed. S2 RN initialed the above treatment on the TAR as completed on 11/02/2024. S3 RN initialed the above treatment as completed on 11/05/2025. Observation on 11/07/2024 at 1:01 p.m. revealed Resident #3 was seated in a wheelchair near the nurse's station. Resident #3's right lower leg was noted with a skin tear, and had a blood stained clear bandage, that did not cover the entire area of the skin tear. Observation revealed the clear bandage was dated 11/02/2024. Observation and interview of Resident #3 on 11/07/2024 at 1:10 p.m. with S2 RN revealed a clear bandage to Resident #3's right lower leg. The clear bandage was blood stained and dated 11/02/2024 with initials on it. S2 RN confirmed the date on the bandage read 11/02/2024 and it was her initials on the bandage from 11/02/2024, indicating she completed Resident #3's treatment on that date Interview on 11/12/2024 at 9:01 a.m. with S1 DON revealed she had spoken with S3 RN regarding the clear bandage on Resident #3's right lower leg having a date of 11/02/2024. S1 DON stated S3 RN revealed she had initialed Resident #3's TAR on 11/05/2024 , but when she got to Resident #3, she was unable to do the treatment at that time, and forgot to go back to do it. S1 DON confirmed Resident #3's dressing change to her right lower leg skin tear should have been done on 11/05/2024, and it had not been. Telephone interview on 11/12/2024 at 1:45 p.m. with S3 RN revealed she initialed the treatment on the TAR for Resident #3 as having changed the bandage to a skin tear to her right lower leg on 11/05/2024. S3 RN revealed she had attempted to change the bandage on Resident #3's right lower leg, but the resident became agitated. S3 RN revealed she left Resident #3 to calm down, and failed to go back and change the bandage. S3 RN confirmed she did not change the dressing to Resident #3's right lower leg on 11/05/2024 as ordered, but she should have.

Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5) sampled residents. Findings: Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident property, Suspicious Injuries of Unknown Source, Exploitation, with a revision date of 04/25/2024, revealed in part .This policy is against abuse, neglect, exploitation and misappropriation of resident property including abuse by any other person, including, but not limited to: other residents. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. A cognitively impaired resident that hits another resident, may be considered abusive. Physical Abuse: Physical abuse includes, hitting, slapping, pinching, and kicking. Resident #4 Review of the clinical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses that included in part .Parkinson's Disease with Dyskinesia, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Dysarthria, Dysphagia, Aphasia, Unspecified Lack of Coordination, and Age Related Physical Debility. Review of Resident #4's Annual MDS with an ARD of 07/24/2024, revealed Resident #4 had a BIMS score of 8, indicating moderately impaired cognition. The MDS revealed Resident #4 required supervision or touching for: toileting, dressing, personal hygiene and transfers. Resident #4 was independent with eating and partial/moderate assistance for shower/bath. The MDS revealed Resident #4 utilized a walker for mobility. Review of Resident #4's care plan with a target date of 11/04/2024 read in part .I have Impaired Cognitive Function/Dementia or Impaired Thought Process related to Dementia, with interventions that included: I will be provided cues, reoriented and supervised as needed. Resident #5 Review of Resident #5's clinical record revealed an admitted [DATE], with diagnoses that included in part . Dementia in other Diseases classified elsewhere, Mild with Mood Disturbance, Impulse Disorder, Other Alzheimer's Disease and Major Depressive Disorder. Review of Resident #5's Annual MDS with an ARD of 04/24/2024, revealed Resident #5 had a BIMS score of 11, indicating moderately impaired cognition. The MDS revealed Resident #5 was independent with eating and oral hygiene; required supervision or touching assistance with upper body dressing, personal hygiene, and toilet transfer; partial/moderate assistance with shower/bath. The MDS revealed Resident #5 used a manual wheelchair independently for mobility, and had impairment on one side to upper and lower extremities. Review of Resident #5's care plan with a target date of 07/31/2024, revealed in part .I have a behavior problem and will cuss at staff and others; resists care, refuses medications, history of aggression. Diagnosis Impulse Control Disorder with behaviors, with interventions that included: I will be assisted to develop more appropriate methods of coping and interacting with staff and others. I will have interventions as necessary to protect the rights and safety of others. I will be removed from the situation and taken to alternate location as needed. Monitor my episodes of behavior and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document my behavior and potential causes. Review of a facility incident report documented by S2 LPN, and dated 05/21/2024, revealed in part . on 05/21/2024 at 11:40 a.m. while in the dining room, Resident #4 and Resident #5 were involved in a resident to resident altercation. Review of the facility's investigation, documented by S1 Administrator, revealed in part . on 05/21/2024 video surveillance revealed residents were gathering in the dining room for lunch. Resident #5 was observed maneuvering his way through the dining room to his table in a wheelchair, when he encountered Resident #4's walker. Resident #5 was then observed to kick Resident #4's walker to clear the path to his table. Resident #4 was observed grabbing Resident #5's wheelchair to move Resident #5 away from his walker. Resident #5 then threw a small plastic bowl and hit Resident #4 on the left side of his head above the eyebrow area, which resulted in a small laceration. Resident #4 then grabbed Resident #5's arm and both Resident #4 and Resident #5 started hitting at each other. This resulted in a skin tear to Resident #5's left arm. Review of a Treatment Administration Record dated May 2024 read in part .Cleanse laceration to left upper brow with normal saline, apply Bacitracin, cover with Band-Aid one time a day for laceration. Interview with Resident #4 on 08/06/2024 at 12:51 p.m., revealed on 05/21/2024, while in the dining room, Resident #5 kicked his walker, then threw a bowl and hit him over the eye (resident pointed above his left eyebrow). Resident #4 revealed the bowl had caused a cut. Resident #4 stated it hurt when it happened, but it doesn't hurt now. Interview on 08/06/2024 at 1:06 p.m. with S1 Administrator, confirmed video surveillance revealed on 05/21/2024 right before the start of the noon meal, Resident #5 threw a small plastic bowl and hit Resident #4 on the left side of his head above the eyebrow, which resulted in a small laceration. S1 Administrator revealed Resident #4 was administered first-aid and treated at the facility for the small laceration. Interview on 08/06/2024 at 1:42 P.M. with S3 CNA, revealed on 05/21/2024, while leaving the dining room before the start of lunch, she heard a commotion and turned to see Resident #5's hand coming down out the air, and a plastic bowl hitting Resident #4 above his eye, causing it to bleed. S3 CNA revealed Resident #4 and Resident #5 started hitting each other. S3 CNA revealed Resident #5 had scratches to his arm. S3 CNA stated Resident #5 had a habit of pushing his way through the dining room and bumping into other resident's chairs, and then becoming upset. Interview on 08/06/2024 at 2:00 p.m. with S4 CNA revealed she was summoned to the dining room by S3 CNA to help separate Resident #4 and Resident #5 because they were hitting each other.

Based on observations, record review, and interview the facility failed to: 1. ensure the physician was immediatley consulted and the resident's interested family member was notified when a reddened area on the resident's buttock (sacral area) was observed on the morning of 11/27/14; and 2. ensure the physician was immediately consulted with when an open area to the resident's sacrum became infected and was observed to have pus in it on 12/28/14. The total sample size was 5 (#1,#2,#3,#4,#5) sampled residents with pressure ulcers. The facility had a total of 6 residents with pressure ulcers. There was a total of 77 residents according to interview of the Administrator on 2/9/14 at 12:15 p.m. Findings. Review of the facility's policy for Change in Resident Medical Status reflected any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment. Further review of the policy reflected the facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there was a need to alter treatment significantly. Review of Resident #2's face sheet reflected the resident was admitted to the nursing facility on 8/11/14 and readmitted on [DATE]. Review of the resident's [DIAGNOSES REDACTED]. Observation on 2/9/15 at 11:20 a.m. of S3 Treatment Nurse providing wound care to the resident's stage 3 pressure ulcer to her buttock. The area appeared to have pink outer edges with a slough center and the area around the slough was red. Interview on 2/9/15 at 11:25 a.m. with S3 LPN Treatment Nurse during wound care revealed the resident acquired her wound at the facility on 11/27/14. S3 LPN Treatment Nurse stated the wound started with redness to the bony prominence of the resident sacral area. S3 LPN Treatment Nurse also stated when the wound started to worsen, the resident's turn schedule changed to only turn from side to side because the resident enjoyed lying on her back. Further interview with S3 LPN Treatment Nurse revealed the resident's treatment was changed on 1/6/15 from duoderm every three days to cleanse with normal saline and apply Santyl to area. S3 Treatment Nurse also stated the resident was on an air mattress, she was gotten up regularly, and sometimes went out with her family. Review of the Wound Assessment Report dated 11/27/14 and signed by S2 RN and S3 LPN Treatment Nurse reflected a new wound was identified on the resident's sacrum. The report reflected the new wound type as irritation/excoriation that measured 2 cm x 3 cm x 0 depth. The report further reflected that moisture caused the new wound, and the area was described as red or darker pink with moderate irritation. The wound assessment further reflected the resident was noted with dark red excoriation to the sacrum area, her skin was intact at present, and there were no signs/symptom of infection noted. Review of S3 LPN Treatment notes documented on the wound assessment report dated 11/27/14 reflected [MEDICATION NAME] was applied for preventive measures to the area. The report reflected the physician and the RP were notified. Review of the Wound Assessment Report dated 12/26/14 reflected the wound type as irritation/excoriation, and the wound was deteriorated. The measurements was 3.00cm x 3.00cm x 0.10cm depth. Further review of the Wound Assessment Report reflected the wound was red with severe irritation. The report also reflected the physician and responsible party were notified on 12/24/14 and not on 12/26/14 when the assessment was done. S3 LPN Treatment Nurse confirmed that the physician and resident's daughter were notified on 12/24/14 instead of 12/26/14. S3 LPN Treatment Nurse when questioned by the surveyor, did not give a reason why she documented the physician was contacted on 12/24/14 regarding a wound assessment that did not occur until 12/26/14. Review of the Wound Assessment Report dated 1/3/15 reflected the wound was assessed as an irritation/excoriation. Further review of the report reflected the wound had deteriorated and measure 3.50cm x 4.00cm x 0.10cm depth. The wound was described to have Bacterial/[MEDICAL CONDITION] infection, serous Scant drainage and red with severe irritation. Further review of the Wound Assessment Report reflected the doctor and RP were notified on 1/6/15 instead of 1/3/15 when the assessment was done. Review of Departmental Notes dated 11/27/14 at 10:05 p.m. and documented by S4 LPN reflected the resident returned to the facility in a private auto with family. Upon entering the facility, the resident's daughter requested the nurse to come to the resident's room to check an open area on the resident's bottom. The notes further reflected the nurse observed an opened area on the resident's mid sacrum that measured 2cm x 2cm x 0.1cm depth. The doctor was notified and new orders were received to cleanse area with normal saline and apply duoderm every 3 days and prn til healed. The notes further reflected RP here and aware of new orders, and initial treatment administered. Review of the Treatment Record dated 12/28/14 reflected S2 RN Treatment Nurse applied a duoderm to the resident's wound at 9:00 a.m. Review of the Departmental Notes dated 12/28/14 at 5:29 p.m. and documented by S6 LPN reflected the doctor called approximately at 5:00 p.m. and stated that the resident's daughter worked for him and called him stating the resident had a decubitus ulcer on her sacrum with what appeared to be pus coming out of it. The notes reflected a new order for CBC and wound culture of the sacrum in the morning (12/29/14). The Departmental Notes further reflected to advise treatment nurse to start wound care. Review of the Departmental Notes dated 12/29/14 at 4:36 p.m. reflected "wound culture obtained, lab picked up". Review of the Lab Culture Report dated 1/2/15 reflected final report: Escherichia coli heavy growth, [MEDICATION NAME] species light growth, and Staphlococcus Aureus light growth. Further review of the Lab Culture Report dated 1/2/15 reflected that MD notified was hand written on the report. Review of the Treatment notes dated 1/6/15 at 3:19 p.m. and documented by S3 LPN/Treatment Nurse reflected irritation/excoriation to sacrum "is appearing as a stage 3 today with slough noted and scant serous drainage with thick white pus like mixed in". The area had no odor and it was cultured. The culture was noted with ecoli and entercoccus. New order to discontinue duoderm, cleanse area with normal saline, apply santyl and cover with 4 x 4 tape daily. Review of the physician's orders [REDACTED]. Review of the care plan dated 1/7/15 reflected a problem of "Actual Pressure Ulcer present, stage 3 noted to sacrum". Approaches included treatment as ordered, pressure relief mattress in use, turn and reposition every 2 hours, meds as ordered, incontinent care every 2 hours and as needed, encourage po intake, monitor skin daily for changes and notify nurse if present, notify MD of problem s/sx of infection, span air mattress in use for pressure relief, float heels. Interview on 2/10/15 at 7:35 a.m. with S4 LPN revealed on 11/27/14 at 10:05 p.m. the resident returned from being out with her daughter and the daughter asked her to look at her mother's bottom. S4 LPN stated there was no dressing to the area. S4 LPN also revealed that she saw an open wound that was light red and not inflamed. S4 LPN stated the area around the opening was excoriated, and the small indentation she noted look like a pressure area. S4 LPN stated she measured the area while the resident's daughter was watching and the measurements were 2cm x 2cm x 0.1cm depth. S4 LPN also stated she notified the Doctor on his cell phone and told him the resident had a small area with an indentation in the middle and he gave her an order to apply duoderm to the area. S4 LPN stated she informed the oncoming shift of her finding. Interview on 2/10/15 at 9:00 a.m. with the resident's other daughter, revealed she visited her mother the weekend of 12/28/14, and noted the nurse putting a gauze dressing to the resident's buttock. The resident's daughter stated she noticed the wound on the resident's buttock looked like it had pus in it. The daughter stated she informed the doctor (whom she worked for) on 12/28/14, and asked him to order something for it. The daughter stated she did not remember what nurse changed the resident's dressing that weekend. Interview on 2/10/15 at 9:23 a.m. with the resident's daughter revealed she took the resident back to the facility on [DATE] around 10:00 p.m. and informed the nurse to check her mother's buttock. The resident's daughter stated she saw an open wound that looked like a blister that had burst with no skin on top and a red raw spot. The resident's daughter stated she was not informed that the resident had an excoriated area to her buttock prior to taking her home on 11/27/14 at 12:06 p.m. Interview on 2/11/15 at 12:00 p.m. with S3 LPN/Treatment Nurse revealed on 11/27/14 she did not notify the physician or the resident's family member of the resident's new wound. S3 LPN/Treatment Nurse stated she applied Zinc to the area instead of [MEDICATION NAME]. S3 LPN/Treatment Nurse stated she should have contacted the doctor and resident's family regarding the resident's new wound. Interview on 2/11/15 at 12:13 p.m. with S2 RN Treatment Nurse revealed she did not remember what the resident's wound looked like when she performed wound care on 12/28/14 (a Sunday). S2 RN Treatment Nurse further stated that she dressed the resident's wound twice and observed slough both times; however, she could not remember when those times were. S2 RN Treatment Nurse stated she would not have contacted the doctor on a Sunday if she noticed a change in wound status because she felt that was something that could have waited until the following Monday. Interview on 2/11/15 at 12:15 p.m. with S3 LPN Treatment Nurse confirmed that the physician and RP were not notified until 1/6/15 that the wound had worsened. The surveyor questioned S3 LPN Treatment Nurse as to why the physician was notified on 1/6/15 and not 1/3/15 when the wound assessment was done, and S3 LPN Treatment Nurse did not give a reason why the physician was not notified on 1/3/15 when the assessment was done. Interview of the S1 DON on 2/11/15 at 12:30 p.m. revealed that when a nurse writes "MD notified", they pick up the telephone and call the doctor. The surveyor requested to talk with the nurse who hand wrote the MD notification statement on the Lab Culture Report for verification that she called the physician; however, the S1 DON stated the nurse was a part-time nurse and she was not at the facility.

Based on observation, interview, and record review the facility failed to ensure a resident's wound assessments were accurate and reflected the resident's status for 1 resident (#2) of 5 sampled residents (#1,#2,#3,#4,#5)with pressure sores, by failing to: 1. ensure that S2 RN Treatment Nurse Assessed a resident's wound prior to signing the wound treatment record verifying observation and assessment of the wound; 2. ensure the assessments were accurate regarding the resident's wound status; 3. ensure wound assessments were performed weekly as reflected in the facility's wound policy; and 4. ensure that a RN staged the resident's pressure ulcer. The facility had a total of 6 residents with pressure ulcers. The total census of the facility was 77 according to an interview with the facility's Administrator dated 2/9/15 at 12:15 p.m. Findings: Review of Resident #2's face sheet reflected the resident was admitted to the nursing facility on 8/11/14 and readmitted on [DATE]. Review of the resident's [DIAGNOSES REDACTED]. Review of a Wound Assessment Report for the resident dated 11/27/14 with no time, and signed by S2 RN and S3 LPN Treatment Nurse, reflected a new wound was identified on the resident's sacrum. The report identified the new wound type as irritation/excoriation that measured 2 cm x 3 cm x 0 cm depth. The Wound Assessment Report reflected that moisture caused the new wound, and the area was described as red or darker pink with moderate irritation. The assessment further reflected the resident was noted with dark red excoriation to the sacrum area, skin was intact at present, and there were no signs/symptoms of infection noted. Review of S3 LPN Treatment Nurse's notes documented on the wound assessment report dated 11/27/14 reflected a [MEDICATION NAME] was applied for preventive measures to the area. Interview on 2/10/15 at 1:15 p.m. with S2 RN Treatment Nurse revealed that she sometimes would go with S3 LPN Treatment Nurse for weekly assessment of the resident's wound. S2 RN Treatment Nurse confirmed that her electronic signature on all the resident's weekly wound assessments indicated that she had observed the resident's wound and agreed with what S3 LPN Treatment Nurse wrote on the resident's Wound Assessment Report. Interview on 2/10/15 at 1:25 p.m. with S3 LPN Treatment Nurse revealed that she assessed the resident's sacral area on the morning of 11/27/14. S3 LPN Treatment Nurse confirmed S2 RN Treatment Nurse electronically signed the report indicating that she had assessed the area. Review of the facility's nursing schedule with the S1 DON reflected S2 RN Treatment Nurse was not scheduled to work on 11/27/14. Interview on 2/10/15 at 1:27 p.m. with S2 RN Treatment Nurse confirmed she did not work on 11/27/14, and also confirmed that her electronic signature was on the resident's Wound Assessment Report dated 11/27/14. Interview on 2/10/15 at 7:35 a.m. with S4 LPN revealed on 11/27/14 at 10:05 p.m. the resident returned from being out with her daughter and the daughter asked her to look at her mother's bottom. S4 LPN stated there was no dressing to the area. S4 LPN also revealed that she saw an open wound that was light red and not inflamed. S4 LPN stated the area around the opening was excoriated, and the small indentation she noted look like a pressure area. S4 LPN stated she measured the area while the resident's daughter was watching and the measurements were 2cm x 2cm x 0.1cm depth. S4 LPN also stated she notified the Doctor on his cell phone and told him the resident had a small area with an indentation in the middle and he gave her an order to apply duoderm to the area. S4 LPN stated she informed the oncoming shift of her finding. Interview on 2/10/15 at 9:23 a.m. with resident #2's daughter revealed she took the resident back to the facility on [DATE] around 10:00 p.m. and informed the nurse to check her mother's buttock. The resident's daughter stated she saw an open wound that looked like a blister that had burst, with no skin on top and a red raw spot. Review of Departmental Notes dated 11/27/14 at 12:06 p.m. reflected resident #2 went out of the facility with her family. Further review of the Departmental Notes documented by S4 LPN and dated 11/27/14 at 10:24 p.m. reflected the resident returned to the facility on [DATE] at 10:05 p.m. S4 LPN documented the following: resident returned to the facility in a private auto with family. Upon entering the facility, S6 resident #2's daughter requested that the nurse come to the resident's room to check an open area on the resident's bottom. The Departmental notes further reflected the nurse observed an opened area on the resident's mid sacrum that measured 2cm x 2cm x 0.1cm depth. The doctor was notified and new orders were received to cleanse area with normal saline and apply duoderm every 3 days and prn til healed. The notes further reflected RP here and aware of new orders, and initial treatment administered. Further review of the resident's clinical record reflected there was no documentation to reflect the opened area to the resident's sacrum was assessed and staged by a RN. Review of the Physician's Progress Report dated 12/3/14 reflected the resident had an ulcer on her buttock (sacral area), a small open area but clean; continue wound care daily. However, review of the Wound Assessment Report dated 12/4/14 and signed by S2 RN and S3 LPN Treatment Nurses reflected the wound type as irritation/excoriation to the sacrum instead of an small opened area, ulcer to the buttock as reflected in the Physician's Progress Report dated 12/3/14. Further review of the Wound Assessment Report dated 12/4/14 reflected the area was light pink with mild irritation and measured of 2.0cm x 2.0cm x 0cm. Interview of the S1 DON on 2/10/15 at 2:00 p.m. revealed that according to the facility's Wound Assessment Policy, a stage II pressure ulcer was an open ulcer with a red-pink wound bed without slough, and confimed S4 LPN's wound assessment of resident #2's sacrum on 11/27/14 at 10:05 p.m. was a stage II pressure ulcer, and should have been assessed by a RN within 24 hours of discovery. Interview on 2/11/15 at 10:15 a.m. with S1 DON reflected that the Wound Assessment Reports were done weekly. However, review of the resident's clinical record reflected a weekly wound assessment had not been performed for 12/11/14. S2 RN and S3 LPN Treatment Nurses and S1 DON confirmed that there was no Wound Assessment Report done on 12/11/14 and should have been. Further interview with S2 RN and S3 LPN Treatment Nurses on the above date and time revealed they did not know the physician had documented the resident's wound as an ulcer on 12/3/14. They stated that they did not read the physician's progress notes. Review of the resident #2's clinical record reflected the resident was hospitalized from [DATE] to 12/16/14. Review of the weekly Wound Assessment Report dated 12/16/14 reflected the wound type as irritation/excoriation to the resident's sacrum, the status was deteriorated, and the measurements were 3cm x 3cm x .2cm. The report reflected the wound area was red or darker pink with moderate irritation. The Wound Assessment Report reflected the resident returned to the facility with excoriation around sacrum continued, no drainage, skin intact, but slightly redder than when resident previously went to hospital, and duoderm was continued to the area. However, although S3 LPN/treatment note for 12/16/14 reflected the resident's skin was intact, S3 LPN Treatment Nurse documented a measurement that reflected a 0.2cm depth. The report was electronically signed by S2 RN and S3 LPN Treatment Nurses. Further review of the resident's clinical record reflected a weekly Wound Assessment Report had not been completed for 12/23/14. Interview on 2/11/15 at 10:25 a.m. with S2 RN and S3 LPN Treatment Nurses, and S1 DON confirmed that there was no Wound Assessment Report done for 12/23/14. S1 DON stated a Wound Assessment Report should have been done on 12/23/14. The next wound assessment was not preformed until 12/26/14 and signed by S2 RN and S3 LPN Treatment Nurses. The report reflected the wound type as irritation/excoriation to the resident's sacrum and the wound had deteriorated. The measurements had increased in size to 3cm x 3cm x .10cm. The report also reflected the area was red with severe irritation. Review of the Departmental Notes dated 12/28/14 at 5:29 p.m. and documented by S6 LPN reflected the doctor called approximately at 5:00 p.m. and stated that the resident's daughter worked for him and called him stating the resident had a decubitus ulcer on her sacrum with what appeared to be pus coming out of it. The notes reflected a new order for CBC and wound culture of the sacrum in the morning (12/29/14). Review of the resident's clinical record reflected there was no wound assessment done on 12/28/14 after the MD called and reported a change in the resident's wound status. Review of the Departmental Notes dated 12/29/14 at 4:36 p.m. reflected "wound culture obtained, lab picked up". There was no documentation to reflect an assessment of the wound was done on 12/29/14. Review of the Lab culture report dated 1/2/15 reflected final report: Escherichia coli heavy growth, [MEDICATION NAME] species light growth, and staphlococcus aureus light growth. Further review of the Lab culture report reflected MD was notified 1/2/15. The next wound assessment was not performed until 1/3/15. Review of the weekly Wound Assessment Report dated 1/3/15 and signed by S2 RN and S3 LPN Treatment Nurses, reflected the wound type as irritation/excoriation to the resident's sacrum, and the status of the wound was deteriorated. The measurements had increase in size to 3.50cm x 4.00cm x .10cm. The report also reflected the area was red with severe irritation with serous/scant drainage. The report reflected the cause was Bacterial/[MEDICAL CONDITION] infection with malodorous and purulent drainage. The S3 LPN Treatment Nurse's note dated 1/3/15 and documented on the Wound Assessment Report also reflected the resident's sacrum area appeared as a "stage 3 today with slough noted, scant serous drainage with thick white pus like mixed in, no odor, area cultured, noted with Ecoli and Entercoccus". However, there was no documentation to reflect a RN assessed the area for wound stage. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview on 2/11/15 at 12:13 p.m. with S2 RN Treatment Nurse confirmed that she worked and applied a duoderm dressing to the resident's wound on 12/28/14; however, she stated she did not remember what the resident's wound looked like. S2 RN Treatment nurse further stated that she dressed the resident's wound twice and observed slough both times, but she could not remember when those times were. Review of the facility's policy on Skin and wound Care reflected the Wound Care/Treatment Nurse or DON designated/assigned licensed nursing staff enters weekly documentation on all existing wound sites. Further review of the policy reflected wound staging was always preformed per trained RN. Interview on 2/11/15 at 12:13 p.m. with S2 RN and S3 LPN Treatment Nurses, and S1 DON confirmed that there were no Wound Assessment Reports completed on 12/11/14 and 12/23/14 as per wound care policy, and should have been. Additionally, a wound assessment was not done until 1/3/14, after the MD called the facility and reported a change in wound status on 12/28/14.

Based on observation, record review, and interview the facility failed to ensure that a resident who developed a pressure sore received the necessary treatment and service to promote healing, prevent infection, and prevent worsening of the pressure ulcer for 1 (#2) of 5 residents (#1,#2,#3,#4,#5) with pressure sores out of the facility total of 6 residents with pressure ulcers by failing to: 1. immediately consult with a resident's physician when a reddened area on the resident's buttock (sacral area) was observed on the morning of 11/27/14; 2. immediately consult with the Physician when an open area to the resident's sacrum became infected and was observed to have pus in it on 12/28/14; and 3. Follow the facility's policy and procedures to ensure wound assessments were accurate and reflected the actual status of the resident's wound, ensure wound assessments were performed weekly, and ensure that a RN staged the resident's pressure ulcer. This failed practice resulted in actual harm for resident #2. An excoriated/irritated area that measured 2cm x 3 cm x 0 cm was observed on the resident's sacrum the morning of 11/27/14 prior to her leaving out of the facility with family. The physician and RP were not notified. On 12/28/14 at 5:29 p.m. documentation by S6 LPN reflected the doctor called at 5:00 p.m. and stated that the resident's daughter worked for him and called him stating the resident had a decubitus ulcer on her sacrum with what appeared to be pus coming out of it. Review of the Lab Culture Report dated 1/2/15 reflected final report: Escherichia coli heavy growth, [MEDICATION NAME] species light growth, and Staphlococcus Aureus light growth. The physician's orders [REDACTED]. The total census of the facility was 77 according to an interview with the facility's Administrator dated 2/9/15 at 12:15 p.m. Findings: Review of Resident #2's face sheet reflected the resident was admitted to the nursing facility on 8/11/14 and readmitted on [DATE]. Review of the resident's [DIAGNOSES REDACTED]. Observation on 2/9/15 at 11:20 a.m. of S3 Treatment Nurse providing wound care to the resident's stage 3 pressure ulcer to her buttock. The area appeared to have pink outer edges with a slough center and the area around the slough was red. Interview on 2/9/15 at 11:25 a.m. with S3 LPN Treatment Nurse during wound care revealed the resident acquired her wound at the facility on 11/27/14. S3 LPN Treatment Nurse stated the wound started with redness to the bony prominence of the resident sacral area. S3 LPN Treatment Nurse also stated when the wound started to worsen, the resident's turn schedule changed to only turn from side to side because the resident enjoyed lying on her back. Further interview with S3 LPN Treatment Nurse revealed the resident's treatment was changed on 1/6/15 from duoderm every three days to cleanse with normal saline and apply Santyl to area. S3 Treatment Nurse also stated the resident was on an air mattress, she was gotten up regularly, and sometimes went out with her family. Review of a Wound Assessment Report for the resident dated 11/27/14 with no time, and signed by S2 RN and S3 LPN Treatment Nurse, reflected a new wound was identified on the resident's sacrum. The report identified the new wound type as irritation/excoriation that measured 2 cm x 3 cm x 0 cm depth. The Wound Assessment Report reflected that moisture caused the new wound, and the area was described as red or darker pink with moderate irritation. The assessment further reflected the resident was noted with dark red excoriation to the sacrum area, skin was intact at present, and there were no signs/symptoms of infection noted. Review of S3 LPN Treatment Nurse's notes documented on the wound assessment report dated 11/27/14 reflected a [MEDICATION NAME] was applied for preventive measures to the area. The report reflected the physician and the RP were notified. Review of Departmental Notes dated 11/27/14 at 10:05 p.m. and documented by S4 LPN reflected the resident returned to the facility in a private auto with family. Upon entering the facility, the resident's daughter requested the nurse to come to the resident's room to check an open area on the resident's bottom. The notes further reflected the nurse observed an opened area on the resident's mid sacrum that measured 2cm x 2cm x 0.1cm depth. The doctor was notified and new orders were received to cleanse area with normal saline and apply duoderm every 3 days and prn til healed. The notes further reflected RP here and aware of new orders, and initial treatment administered. Interview on 2/10/15 at 7:35 a.m. with S4 LPN revealed on 11/27/14 at 10:05 p.m. the resident returned from being out with her daughter and the daughter asked her to look at her mother's bottom. S4 LPN stated there was no dressing to the area. S4 LPN also revealed that she saw an open wound that was light red and not inflamed. S4 LPN stated the area around the opening was excoriated, and the small indentation she noted look like a pressure area. S4 LPN stated she measured the area while the resident's daughter was watching and the measurements were 2cm x 2cm x 0.1cm depth. S4 LPN also stated she notified the Doctor on his cell phone and told him the resident had a small area with an indentation in the middle and he gave her an order to apply duoderm to the area. S4 LPN stated she informed the oncoming shift of her finding. Interview on 2/10/15 at 9:23 a.m. with the resident's daughter revealed she took the resident back to the facility on [DATE] around 10:00 p.m. and informed the nurse to check her mother's buttock. The resident's daughter stated she saw an open wound that looked like a blister that had burst with no skin on top and a red raw spot. The resident's daughter stated she was not informed that the resident had an excoriated area to her buttock prior to taking her home on 11/27/14 at 12:06 p.m. Interview on 2/10/15 at 1:15 p.m. with S2 RN Treatment Nurse revealed that she sometimes would go with S3 LPN Treatment Nurse for weekly assessment of the resident's wound. S2 RN Treatment Nurse confirmed that her electronic signature on all the resident's weekly wound assessments indicated that she had observed the resident's wound and agreed with what S3 LPN Treatment Nurse wrote on the resident's Wound Assessment Report. Interview on 2/10/14 at 1:25 p.m. with S3 LPN Treatment Nurse revealed that she assessed the resident's sacral area on the morning of 11/27/14. S3 LPN Treatment Nurse confirmed S2 RN Treatment Nurse electronically signed the report indicating that she had assessed the area. Review of the facility's nursing schedule with the S1 DON reflected S2 RN Treatment Nurse was not scheduled to work on 11/27/14. Interview on 2/10/15 at 1:27 p.m. with S2 RN Treatment Nurse confirmed she did not work on 11/27/14, and also confirmed that her electronic signature was on the resident's Wound Assessment Report dated 11/27/14. Interview on 2/11/15 at 12:00 p.m. with S3 LPN/Treatment Nurse revealed on 11/27/14 she did not notified the physician or the resident's family member of the resident's new wound. S3 LPN/Treatment Nurse stated she applied Zinc to the area instead of [MEDICATION NAME]. S3 LPN/Treatment Nurse stated she should have contacted the doctor and resident's family regarding the resident's new wound. Further review of the resident's clinical record reflected there was no documentation to reflect the opened area to the resident's sacrum was assessed and staged by a RN. Review of the Physician's Progress Report dated 12/3/14 reflected the resident had an ulcer on her buttock (sacral area), a small open area but clean; continue wound care daily. However, review of the Wound Assessment Report dated 12/4/14 and signed by S2 RN and S3 LPN Treatment Nurses reflected the wound type as irritation/excoriation to the sacrum instead of an small opened area, ulcer to the buttock as reflected in the Physician's Progress Report dated 12/3/14. Further review of the Wound Assessment Report dated 12/4/14 reflected the area was light pink with mild irritation and measured of 2.0cm x 2.0cm x 0cm. Interview of the S1 DON on 2/10/14 at 2:00 p.m. revealed that according to the facility's Wound Assessment Policy, a stage II pressure ulcer was an open ulcer with a red-pink wound bed without slough, and confimed S4 LPN's wound assessment of resident #2's sacrum on 11/27/14 at 10:05 p.m. was a stage II pressure ulcer, and should have been assessed by a RN within 24 hours of discovery. Interview on 2/11/15 at 10:15 a.m. with S1 DON reflected that the Wound Assessment Reports were done weekly. However, review of the resident's clinical record reflected a weekly wound assessment had not been performed for 12/11/14. S2 RN and S3 LPN Treatment Nurses and S1 DON confirmed that there was no Wound Assessment Report done on 12/11/14 and should have been. Further interview with S2 RN and S3 LPN Treatment Nurses on the above date and time revealed they did not know the physician had documented the resident's wound as an ulcer on 12/3/14. They stated that they did not read the physician's progress notes. Review of the resident #2's clinical record reflected the resident was hospitalized from [DATE] to 12/16/14. Review of the weekly Wound Assessment Report dated 12/16/14 reflected the wound type as irritation/excoriation to the resident's sacrum, the status was deteriorated, and the measurements were 3cm x 3cm x .2cm. The report reflected the wound area was red or darker pink with moderate irritation. The Wound Assessment Report reflected the resident returned to the facility with excoriation around sacrum continued, no drainage, skin intact, but slightly redder than when resident previously went to hospital, and duoderm was continued to the area. However, although S3 LPN/treatment note for 12/16/14 reflected the resident's skin was intact, S3 LPN Treatment Nurse documented a measurement that reflected a 0.2cm depth. The report was electronically signed by S2 RN and S3 LPN Treatment Nurses. The report reflected the physician and the RP were notified. Further review of the resident's clinical record reflected a weekly Wound Assessment Report had not been completed for 12/23/14. Interview on 2/11/15 at 10:25 a.m. with S2 RN and S3 LPN Treatment Nurses, and S1 DON confirmed that there was no Wound Assessment Report done for 12/23/14. S1 DON stated a Wound Assessment Report should have been done on 12/23/14. Review of the Wound Assessment Report dated 12/26/14 reflected the wound type as irritation/excoriation, and the wound was deteriorated. The measurements was 3.00cm x 3.00cm x 0.10cm depth. Further review of the Wound Assessment Report reflected the wound was red with severe irritation. The report also reflected the physician and responsible party were notified on 12/24/14 and not on 12/26/14 when the assessment was done. S3 LPN Treatment Nurse confirmed that the physician and resident's daughter were notified on 12/24/14 instead of 12/26/14. S3 LPN Treatment Nurse when questioned by the surveyor, did not give a reason why she documented the physician was contacted on 12/24/14 regarding a wound assessment that did not occur until 12/26/14. Review of the Treatment Record dated 12/28/14 reflected S2 RN Treatment Nurse applied a duoderm to the resident's wound at 9:00 a.m. Interview on 2/10/15 at 9:00 a.m. with the resident's other daughter, revealed she visited her mother the weekend of 12/28/14, and noted the nurse putting a gauze dressing to the resident's buttock. The resident's daughter stated she noticed the wound on the resident's buttock looked like it had pus in it. The daughter stated she informed the doctor (whom she worked for) on 11/28/14, and asked him to order something for it. The daughter stated she did not remember what nurse changed the resident's dressing that weekend. Review of the Departmental Notes dated 12/28/14 at 5:29 p.m. and documented by S6 LPN reflected the doctor called approximately at 5:00 p.m. and stated that the resident's daughter worked for him and called him stating the resident had a decubitus ulcer on her sacrum with what appeared to be pus coming out of it. The notes reflected a new order for CBC and wound culture of the sacrum in the morning (12/29/14). The Departmental Notes further reflected to advise treatment nurse to start wound care. Interview on 2/11/15 at 12:13 p.m. with S2 RN Treatment Nurse revealed she did not remember what the resident's wound looked like when she performed wound care on 12/28/14 (a Sunday). S2 RN Treatment Nurse further stated that she dressed the resident's wound twice and observed slough both times; however, she could not remember when those times were. S2 RN Treatment Nurse stated she would not have contacted the doctor on a Sunday if she noticed a change in wound status because she felt that was something that could have waited until the following Monday. Review of the resident's clinical record reflected there was no wound assessment done on 12/28/14 after the MD called and reported a change in the resident's wound status. Review of the Departmental Notes dated 12/29/14 at 4:36 p.m. reflected "wound culture obtained, lab picked up". There was no documentation to reflect an assessment of the wound was done on 12/29/14. Review of the Lab Culture Report dated 1/2/15 reflected final report: Escherichia coli heavy growth, [MEDICATION NAME] species light growth, and Staphlococcus Aureus light growth. Further review of the Lab Culture Report dated 1/2/15 reflected that MD notified was hand written on the report. Interview of the S1 DON on 12/11/14 at 12:30 p.m. revealed that when a nurse writes "MD notified", they pick up the telephone and call the doctor. The surveyor requested to talk with the nurse who hand wrote the MD notification statement on the Lab Culture Report for verification that she called the physician; however, the S1 DON stated the nurse was a part-time nurse and she was not at the facility. The next wound assessment was not performed until 1/3/15. Review of the weekly Wound Assessment Report dated 1/3/15 and signed by S2 RN and S3 LPN Treatment Nurses, reflected the wound type as irritation/excoriation to the resident's sacrum, and the status of the wound was deteriorated. The measurements had increase in size to 3.50cm x 4.00cm x .10cm. The report also reflected the area was red with severe irritation with serous/scant drainage. The report reflected the cause was Bacterial/[MEDICAL CONDITION] infection with malodorous and purulent drainage. The S3 LPN Treatment Nurse's note dated 1/3/15 and documented on the Wound Assessment Report also reflected the resident's sacrum area appeared as a "stage 3 today with slough noted, scant serous drainage with thick white pus like mixed in, no odor, area cultured, noted with Ecoli and Entercoccus". Further review of the Wound Assessment Report reflected the doctor and RP was notified on 1/6/15 instead of 1/3/15 when the assessment was done. The report also reflected no documentation that a RN assessed the area for wound stage. Review of the Wound Assessment Report dated 1/3/15 reflected the wound was assessed as an irritation/excoriation. Further review of the report reflected the wound had deteriorated and measure 3.50cm x 4.00cm x 0.10cm depth. The wound was described to have Bacterial/[MEDICAL CONDITION] infection, serous Scant drainage and red with severe irritation. Interview on 2/11/15 at 12:15 p.m. with S3 LPN Treatment Nurse confirmed that the physician and RP were not notified until 1/6/15 that the wound had worsened. The surveyor questioned S3 LPN Treatment Nurse as to why the physician was notified on 1/6/15 and not 1/3/15 when the wound assessment was done, and S3 LPN Treatment Nurse did not give a reason why the physician was not notify on 1/3/15 when the assessment was done. Review of the Treatment notes dated 1/6/15 at 3:19 p.m. and documented by S3 LPN/Treatment Nurse reflected irritation/excoriation to sacrum "is appearing as a stage 3 today with slough noted and scant serous drainage with thick white pus like mixed in". The area had no odor and it was cultured. The culture was noted with ecoli and entercoccus. New order to discontinue duoderm, cleanse area with normal saline, apply santyl and cover with 4 x 4 tape daily. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview on 2/11/15 at 12:13 p.m. with S2 RN and S3 LPN Treatment Nurses, and S1 DON confirmed that there were no Wound Assessment Reports completed on 12/11/14 and 12/23/14 as per wound care policy, and should have been. Additionally, a wound assessment was not done until 1/3/14, after the MD called the facility and reported a change in wound status on 12/28/14. Review of the care plan dated 1/7/15 reflected a problem of "Actual Pressure Ulcer present, stage 3 noted to sacrum". Approaches included treatment as ordered, pressure relief mattress in use, turn and reposition every 2 hours, meds as ordered, incontinent care every 2 hours and as needed, encourage po intake, monitor skin daily for changes and notify nurse if present, notify MD of problem s/sx of infection, span air mattress in use for pressure relief, float heels. Review of the facility's policy on Skin and wound Care reflected the Wound Care/Treatment Nurse or DON designated/assigned licensed nursing staff enters weekly documentation on all existing wound sites. Further review of the policy reflected wound staging was always preformed per trained RN. Review of the facility's policy for Change in Resident Medical Status reflected any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment. Further review of the policy reflected the facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there was a need to alter treatment significantly.

Based on record review and interview the facility failed to ensure the resident's physician was immediately consulted with when the resident who was a known diabetic and had a history of [REDACTED].#5) for 1 of 5 sampled residents out of a total of 20 residents with a [DIAGNOSES REDACTED]. The facility failed to: 1. immediately notify the resident's (#5) physician when he had a violent episode of vomiting during the supper meal service; 2. immediately notify the resident's physician when the resident again vomited between 7:30 p.m. - 8:00 p.m. that same evening; 3. follow the written policy and procedure concerning Change in Resident Medical Status which stated that a significant change in the resident's physical condition the facility must immediately consult with the resident's physician. On 10/10/10 at approximately 5:30 p.m. resident #5 experienced a violent episode of vomiting during the supper meal. The resident's nurse was immediately informed that the resident had vomited in the dining room. The resident was placed in Immediate Jeopardy when the resident's nurse failed to notify/consult the physician. The resident vomited again that evening around 7:30 p.m. - 8:00 p.m. and the night nurse was notified by the CNA that the resident had vomited again (2nd time) and complained of feeling bad. The nurse failed to notify/consult the resident's physician. Resident # 5 was transferred to the hospital after being found on 10/11/10 at 5:30 a.m. lethargic, had projectile vomited, had a blood glucose that registered "high" and had a O2Sat of 86%. The Immediate Jeopardy ended for the resident when transferred via ambulance to the emergency roiagnom on [DATE] at 5:55 a.m. and was assessed to have a blood glucose of 977 and a probable Left Lower Lobe Infiltrate or Atelectasis. The resident was later transferred from the local hospital, to another hospital on [DATE] at 11:15 a.m. where he was admitted with a [DIAGNOSES REDACTED]. The other 74 residents in the facility who had the potential to require consultation with their physician due to change in condition were at risk of potential for more that minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's physicians were notified of changes in condition. The deficient practice continues at a scope and severity of "E" for the other residents who had the potential to require an assessment of a change in condition and at actual harm for resident #5.. Findings: Review of a Nursing Facility to Hospital Transfer form dated 7/19/10 at 9:30 a.m. reflected the resident was transfer for projectile vomiting X 3. Review of the nurses' notes dated 7/19/10 at 5:40 a.m. reflected the resident had experienced projectile vomiting and had a blood glucose of 484. Further review of the nurses' notes reflected at 7:50 a.m. the resident had 2 more episodes of projectile vomiting. At 9:30 a.m. reflected the resident was transferred to the hospital per ambulance Review of the nurses' noted dated 7/19/10 at 5:00 p.m. reflected the resident returned to the facility with a [DIAGNOSES REDACTED]. Interview with S1DON on 10/27/10 at 1:45 p.m. confirmed on 7/19/10 the resident was transferred to the emergency room due to him projectile vomiting three times and having a 484 blood glucose level. The resident was diagnosed with [REDACTED]. Review of the nurses' notes reflected no documentation from 9/29/10 at 2:30 p.m. until 10/11/10 at 5:30 a.m. when resident #5 was found in bed breathing rapidly, cool to touch, stating "I feel bad all over", had projectile vomiting noted to be dark green in color, and was very weak. Further documentation of the resident's nurses' notes reflected a FSBS that was to high to register on the glucometer, a temperature of 99.1(ax), pulse - 114, respirations - 16 and blood pressure of 114/48. The nurses' notes reflected an order was received to send resident to the emergency room and the responsible party was notified and was "ok" with the resident being transferred. The nurses' notes on 10/11/10 at 5:55 a.m. revealed the resident went to the hospital per ambulance. Review of the Nursing Facility to Hospital Transfer form reflected on 10/11/10 at 5:55 a.m. the resident was transferred. Documentation for the reason for transfer/additional information reflected the resident was weak/lethargic, extremities were cold to touch. the resident complained of generalized pain and not feeling well, the FSBS was to high to register, and the resident had projectile vomiting. Further review of the transfer form reflected the resident's vital signs at 5:35 a.m. reflected the resident's Pulse 114, Respirations 16, Blood Pressure 114/48, Temperature 99.1(ax) and his O2Sat was 86% on room air. Phone interview with the S7LPN on 10/26/10 at 3:40 p.m. confirmed she worked 7:00 p.m. - 7:00 a.m. on 10/10/10 and was resident #5's nurse that night. S7LPN stated she had talked with the resident that night during med pass time and he took his medications without any problems. S7LPN stated the resident complained he did not feel good, but stated he said that every night. She also stated she did a walk through at 2:00 a.m. that morning to make sure all of her residents were breathing. Further interview with S7LPN revealed at 5:00 a.m. she started performing her morning blood glucose checks on her diabetic residents and arrived at the resident's room around 5:30 a.m. She stated she noticed upon entering the resident's room he wasn't breathing right and was cool to touch. She stated she noticed he must have projectile vomited because of where the vomit was located on his linens and he still had green vomitus on his teeth. S7LPN stated the resident was lying flat in bed and that was why she thought he must have projectile vomited. S7LPN stated she did not receive report from the nurse from the previous shift that the resident had vomited during the supper meal or that the resident was having any other problems. S7LPN also stated that she received no report during her shift that the resident had vomited until she noticed it upon entering the resident's room at 5:30 a.m. Interview on 10/26/10 at 3:50 p.m. with S3Adm. Assistant revealed that at around 5:30 p.m. on 10/10/10 she heard from her office, which was across the hall at any angle, a resident violently vomiting in the dining area. S3Adm. Assistant stated she went to the dining room and observed the resident vomiting and S4CNA trying to assist the resident in turning his head to the side to prevent him from vomiting on the other residents at the table. S3Adm. Assistant stated she went to the nurses station as S4CNA was wheeling the resident out of the dining room and told the staff that was in the nurses station the resident had just vomited. S3Adm. Assistant stated she was directly in front of S5LPN (the resident' nurse) when she reported the resident had vomited. S3Adm. Assistant stated S5LPN looked directly at her when she reported it. S3Adm. Assistant also revealed S8LPN was also in the nurses' station when she reported it. Phone interview with S5LPN on 10/28/10 at 10:25 a.m. stated she did not hear S3Adm. Assistant report that the resident had vomited in the dining room during the supper meal on 10/10/10. S5LPN confirmed she worked on 10/10/10 from 7:00 a.m. to 7:00 p.m. and that she received report that morning resident #5's blood sugar was elevated and he had received insulin per sliding scale as order at 6:00 a.m. S5LPN confirmed that she did not assess the resident after he vomited because she did not know he had vomited. S5LPN confirmed that she did not notify the resident's physician of any problems related to the resident on 10/10/10. Interview with the S6Ward Clerk on 10/26/10 at 4:15 p.m. confirmed she was worked from 8:00 a.m. to 8:00 p.m. on 10/10/10 and was present when S3Adm. Assistant came to the nurses' station and reported to the resident's nurse that he had vomited in the dining room. S6Ward Clerk stated she asked S3Adm. Assistant what was that, because she had heard the resident vomit from the nurses' station. Review of an undated statement provided by S1DON written by S8LPN reflected S8LPN heard S3Adm. Assistant ask the S6Ward Clerk to call for housekeeping to the dining room because resident #5 had thrown up. S3Adm. Assistant then told the hall nurse S5LPN that the resident had thrown up in the dining room and S5LPN then went down 300 hall (resident #5 was on the 400 hall) to do evening meds. Phone interview with S4CNA on 10/26/10 at 4:30 p.m. confirmed she worked from 2:00 p.m. to 6:00 a.m. on 10/10/10 to 10/11/10. S4CNA revealed she was passing out the supper meal trays when resident #5 began to vomit. S4CNA stated there were no nurses in the dining room at that time and she was trying to keep the resident from vomiting on other residents. S4CNA stated the vomiting was projectile. S4CNA confirmed S3Adm. Assistant came into the dining room when the resident was vomiting. S4CNA stated she took the resident to his room while S3Adm. Assistant went to the nurses' station and reported the resident had vomited. S4CNA confirmed that while she was in the resident's room no nurse came in and checked on him. Further interview with S4CNA confirmed the resident vomited again at approximately 7:30 p.m. to 8:00 p.m.. S4CNA stated she cleaned the resident up and reported to S7LPN that the resident had vomited again (2nd time). S4CNA stated S7LPN went to the resident's room. After interviewing the S4CNA, another phone interview was placed to S7LPN on 10/26/10 at 4:40 p.m., at which point she confirmed S4CNA had reported her that the resident had vomited around 7:30 - 8:00 p.m. and that she went to the resident's room to check on him. S7LPN confirmed she did not assess the resident's vital signs or his blood sugar. S7LPN confirmed she looked at resident and talked to him. S7LPN confirmed she did not document the resident's vomiting because she did not see any vomit. S7LPN confirmed she asked the resident how he was feeling and he stated that he felt bad all over, but did not look like he was in any distress and showed no signs that something was wrong. S7LPN confirmed she did not notify the physician of the resident's change in condition related to his vomiting at the supper meal or at 7:30 p.m. - 8:00 p.m. (2nd time) or that he complained of feeling bad all over. Review of the resident's Comprehensive Care Plan with a goal date of 11/10/10 reflected the resident had a problem with potential for Gastrointestinal upset with an approach that included to observe the resident for complaints of GI upset and report to the physician. Review of the facility's Change in Resident Medical Status policy reflected the facility must immediately consult with the resident's physician when a significant change in the resident's status occurs. Interview with the S1DON on 10/27/10 at 9:00 a.m. confirmed S5LPN and S7LPN both should have notified the resident's physician when the resident began vomiting and when he vomited again (2nd time). Further interview with the S1DON on 10/27/10 at 1:45 p.m. at that time confirmed the staff should have been aware that vomiting was a symptom of his [MEDICAL CONDITION]. Review of the hospital emergency room Record dated 10/11/10 at 6:44 a.m. reflected the resident's Clinical Impression was [MEDICAL CONDITION]. Review of the Lab Summary of a Chemistry drawn at 7:04 a.m. reflected the resident's Glucose level was 977. Review of the CXR Impression dated 10/11/10 at 7:43 a.m. reflected a suggestion of small Left Pleural effusion and probable Left Lower Lobe Infiltrate or Atelectasis.

Based on record review and interview the facility failed to ensure a resident was assessed relevant to his [DIAGNOSES REDACTED]. The facility also failed to assess the resident's lungs after the nurse found the resident lethargic, rapid breathing, had projectile vomited, O2Sat of 86%, a blood glucose that registered "high" and complained of generalized pain and not feeling well for 1 of 5 sampled residents out of a total of 20 residents identified as having a [DIAGNOSES REDACTED]. The facility failed to: 1. assess the resident after the resident had a violent episode of vomiting during the supper meal service; 2. assess the resident after the he vomited again that same evening, approximately 2 hours later; 3. assess the resident's lung sounds after finding the resident lethargic, with rapid breathing, cool to touch, O2Sat of 86%, a blood glucose that registered "high" , had been found to have projectile vomited and complained of generalized pain and not feeling well; 4. follow written policy and procedure for assessing for [MEDICAL CONDITION] for early symptoms such as nausea and vomiting. On 10/10/10 at approximately 5:30 p.m. resident #5 experienced a violent episode of vomiting during the supper meal. The resident's nurse was immediately informed that the resident had vomited in the dining room. The resident was placed in Immediate Jeopardy when the nurse failed to assess the resident following the vomiting episode. The resident vomited again that evening around 7:30 - 8:00 p.m. and the night nurse was informed by the CNA that the resident had vomited again and failed to assess the resident. The resident was not assessed until 10/11/10 at 5:30 a.m. when the resident was found in bed breathing rapidly, cool to touch, lethargic, O2Sat of 86%, with a blood glucose that registered "high", had projectile vomited and complained of generalized pain and not feeling well. The Immediate Jeopardy was removed for the resident when he was transferred to the emergency room via ambulance on 10/11/10 at 5:55 a.m., assessed to have a blood glucose level of 977 and a probable Left Lower Lobe Infiltrate or Atelectasis. The resident was transferred from the local hospital, to another hospital on [DATE] at 11:15 a.m. where he was admitted with a [DIAGNOSES REDACTED]. The other 74 residents in the facility who had the potential to require assessment due to change in condition were at risk of potential for more that minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's were assessed routinely and after changes in condition. The deficient practice continues at a scope and severity of "E" for the other residents who had the potential to require an assessment of a change in condition and at actual harm for resident #5. Findings: Review of a Nursing Facility to Hospital Transfer form dated 7/19/10 at 9:30 a.m. reflected the resident was transfer for projectile vomiting X 3. Review of the nurses' notes dated 7/19/10 at 5:40 a.m. reflected the resident had experienced projectile vomiting and had a blood glucose of 484. Further review of the nurses' notes reflected at 7:50 a.m. the resident had 2 more episodes of projectile vomiting. At 9:30 a.m. reflected the resident was transferred to the hospital per ambulance Review of the nurses' noted dated 7/19/10 at 5:00 p.m. reflected the resident returned to the facility with a [DIAGNOSES REDACTED]. Interview with S1DON on 10/27/10 at 1:45 p.m. confirmed on 7/19/10 the resident was transferred to the emergency room due to him projectile vomiting three times and having a 484 blood glucose level. The resident was diagnosed with [REDACTED]. Review of the nurses' notes reflected no documentation from 9/29/10 at 2:30 p.m. until 10/11/10 at 5:30 a.m. when resident #5 was found in bed breathing rapidly, cool to touch, stating "I feel bad all over", had projectile vomiting noted to be dark green in color, and was very weak. Further documentation of the resident's nurses' notes reflected a FSBS that was to high to register on the glucometer, a temperature of 99.1(ax), pulse - 114, respirations - 16 and blood pressure of 114/48. The nurses' notes reflected an order was received to send resident to the emergency room and the responsible party was notified and was "ok" with the resident being transferred. The nurses' notes on 10/11/10 at 5:55 a.m. revealed the resident went to the hospital per ambulance. Review of the Nursing Facility to Hospital Transfer form reflected on 10/11/10 at 5:55 a.m. the resident was transferred. Documentation for the reason for transfer/additional information reflected the resident was weak/lethargic, extremities were cold to touch. the resident complained of generalized pain and not feeling well, the FSBS was too high to register, and the resident had projectile vomiting. Further review of the transfer form reflected the resident's vital signs at 5:35 a.m. reflected the resident's Pulse 114, Respirations 16, Blood Pressure 114/48, Temperature 99.1(ax) and his O2Sat was 86% on room air. Phone interview with the S7LPN on 10/26/10 at 3:40 p.m. confirmed she worked 7:00 p.m. - 7:00 a.m. on 10/10/10 and was resident #5's nurse that night. S7LPN stated she had talked with the resident that night during med pass time and he took his medications without any problems. S7LPN stated the resident complained he did not feel good, but stated he said that every night. She also stated she did a walk through at 2:00 a.m. that morning to make sure all of her residents were breathing. Further interview with S7LPN revealed at 5:00 a.m. she started performing her morning blood glucose checks on her diabetic residents and arrived at the resident's room around 5:30 a.m. She stated she noticed upon entering the resident's room he wasn't breathing right and was cool to touch. She stated she noticed he must have projectile vomited because of where the vomit was located on his linens and he still had green vomitus on his teeth. S7LPN stated the resident was lying flat in bed and that was why she thought he must have projectile vomited. S7LPN stated she did not receive report from the nurse from the previous shift that the resident had vomited during the supper meal or that the resident was having any other problems. S7LPN also stated that she received no report during her shift that the resident had vomited until she noticed it upon entering the resident's room at 5:30 a.m. Interview on 10/26/10 at 3:50 p.m. with S3Adm. Assistant revealed that at around 5:30 p.m. on 10/10/10 she heard from her office, which was across the hall at any angle, a resident violently vomiting in the dining area. S3Adm. Assistant stated she went to the dining room and observed the resident vomiting and S4CNA trying to assist the resident in turning his head to the side to prevent him from vomiting on the other residents at the table. S3Adm. Assistant stated she went to the nurses station as S4CNA was wheeling the resident out of the dining room and told the staff that was in the nurses station the resident had just vomited. S3Adm. Assistant stated she was directly in front of S5LPN (the resident' nurse) when she reported the resident had vomited. S3Adm. Assistant stated S5LPN looked directly at her when she reported it. S3Adm. Assistant also revealed S8LPN was also in the nurses' station when she reported it. Phone interview with S5LPN on 10/28/10 at 10:25 a.m. stated she did not hear S3Adm. Assistant report that the resident had vomited in the dining room during the supper meal on 10/10/10. S5LPN confirmed she worked on 10/10/10 from 7:00 a.m. to 7:00 p.m. and that she received report that morning resident #5's blood sugar was elevated and he had received insulin per sliding scale as order at 6:00 a.m. S5LPN confirmed that she did not assess the resident after he vomited because she did not know he had vomited. Interview with the S6Ward Clerk on 10/26/10 at 4:15 p.m. confirmed she was worked from 8:00 a.m. to 8:00 p.m. on 10/10/10 and was present when S3Adm. Assistant came to the nurses' station and reported to the resident's nurse that he had vomited in the dining room. S6Ward Clerk stated she asked S3Adm. Assistant what was that, because she had heard the resident vomit from the nurses' station. Review of an undated statement provided by the S1DON written by S8LPN reflected S8LPN heard S3Adm. Assistant ask the S6Ward Clerk to call for housekeeping to the dining room because resident #5 had thrown up. S3Adm. Assistant then told the hall nurse S5LPN that the resident hand thrown up in the dining room and S5LPN then went down 300 hall (resident #5 was on the 400 hall) to do evening meds. Phone interview with S4CNA on 10/26/10 at 4:30 p.m. confirmed she worked from 2:00 p.m. to 6:00 a.m. on 10/10/10 to 10/11/10. S4CNA revealed she was passing out the supper meal trays when resident #5 began to vomit. S4CNA stated there were no nurses in the dining room at that time and she was trying to keep the resident from vomiting on other residents. S4CNA stated the vomiting was projectile. S4CNA confirmed S3Adm. Assistant came into the dining room when the resident was vomiting. S4CNA stated she took the resident to his room while S3Adm. Assistant went to the nurses' station and reported the resident had vomited. S4CNA confirmed that while she was in the resident's room no nurse came in and checked on him. Further interview with S4CNA confirmed the resident vomited again at approximately 7:30 p.m. to 8:00 p.m.. S4CNA stated she cleaned the resident up and reported to S7LPN that the resident had vomited again (2nd time). S4CNA stated S7LPN went to the resident's room. After interviewing the S4CNA, another phone interview was placed to S7LPN on 10/26/10 at 4:40 p.m., at which point she confirmed S4CNA had reported her that the resident had vomited around 7:30 - 8:00 p.m. and that she went to the resident's room to check on him. S7LPN confirmed she did not assess the resident's vital signs or his blood sugar. S7LPN confirmed she looked at resident and talked to him. S7LPN confirmed she did not document the resident's vomiting because she did not see any vomit. S7LPN confirmed she asked the resident how he was feeling and he stated that he felt bad all over, but did not look like he was in any distress and showed no signs that something was wrong. Review of the resident's Comprehensive Care Plan with a goal date of 11/10/10 reflected the resident had a problem with potential for Gastrointestinal upset with an approach that included to observe the resident for complaints of GI upset and report to the physician. Review of the facility's [MEDICAL CONDITION] Policy and Procedure reflected to assess the resident for early symptoms that included abdominal pain that can be rigid and have nausea and vomiting. Interview with the S1DON on 10/27/10 at 9:00 a.m. confirmed S5LPN and S7LPN both should have done an assessment of the resident and documented their assessments in the nurses' notes after the resident after had vomited. Further interview with the S1DON at that time confirmed the staff should have been aware that vomiting was a symptom of his [MEDICAL CONDITION]. Review of the hospital emergency room Record dated 10/11/10 at 6:44 a.m. reflected the resident's Clinical Impression was [MEDICAL CONDITION]. Review of the Lab Summary of a Chemistry drawn at 7:04 a.m. reflected the resident's Glucose level was 977. Review of the CXR Impression dated 10/11/10 at 7:43 a.m. reflected a suggestion of small Left Pleural effusion and probable Left Lower Lobe Infiltrate or Atelectasis.

Based on record review and interview the facility failed to ensure a resident received the necessary care and services to attain the highest practicable level of physical and mental well-being for a diabetic resident (#5) by :not assessing the resident after he had violently vomited and continued to vomit; not immediately consulting/notifying the resident physician; not assessing the resident's lungs; and not following the facility's written policy and procedures for 1 of 5 sampled residents out of a total of 20 residents with a [DIAGNOSES REDACTED]. The facility failed to: 1. conduct a nursing assessment for resident #5 who was a known diabetic and had a history of [REDACTED]. 2. conduct a nursing assessment of the resident's lungs after he was found lethargic, rapid breathing, cool to touch, had projectile vomited, a blood glucose that registered "high", a O2 Sat of 86% and complained of generalized pain and not feeling well; 3. immediately consult/notify the resident's physician, after a change in the resident's condition, for the vomiting episodes. 4. follow the written policy and procedures for Change in Resident's Medical Status which stated the facility would consult with the resident's physician when there is a significant change in the resident's physical status and for the written policy and procedure for [MEDICAL CONDITION] to assess the resident for early symptoms such as nausea and vomiting. 5. implement the resident's Comprehensive Care Plan approach that included to observe the resident for complaints of GI upset and report to the physician. On 10/10/10 at approximately 5:30 pm, Resident #5 experienced a violent episode of vomiting during the supper meal. The resident's nurse was immediately informed that the resident had vomited in the dining room. The resident was in Immediate Jeopardy when the nurse failed to assess the resident and notify/consult with physician regarding the change in the resident's condition. The resident vomited again that evening around 7:30 - 8:00 p.m. and the night nurse was informed by the CNA that the resident had vomited again. Again, the nurse failed to assess the resident and consult with the resident's physician. The physician was not notified and consulted with until 10/11/10 at 5:30 a.m. when the resident was found in bed breathing rapidly, cool to touch, lethargic, oxygen saturation of 86%, blood glucose that registered "high", had projectile vomited and complained of generalized pain and not feeling well. the Immediate Jeopardy ended for Resident #5 when he was transferred to the emergency room via ambulance on 10/11/10 at 5:55 a.m.. At the emergency room , the resident was assessed to have a blood glucose level of 977 and a probable Left Lower Lobe Infiltrate or Atelectasis. The resident was transferred from the local hospital, to another hospital on [DATE] at 11:15 a.m. where he was admitted with a [DIAGNOSES REDACTED]. The other 74 residents in the facility have the potential to require assessment and physician consultation due to change in condition. The deficient practice continues for these residents at a potential for more that minimal harm that is not immediate because the facility had not put a plan of action in place to ensure resident's were assessed routinely and after changes in condition and that the resident's physician would be notified and consulted with regarding changes in conditions. The deficient practice continues at a scope and severity of "E" for the other residents who had the potential to require an assessment of a change in condition and an actual harm for resident #5.. Findings: Review of a Nursing Facility to Hospital Transfer form dated 7/19/10 at 9:30 a.m. reflected the resident was transfer for projectile vomiting X 3. Review of the nurses' notes dated 7/19/10 at 5:40 a.m. reflected the resident had experienced projectile vomiting and had a blood glucose of 484. Further review of the nurses' notes reflected at 7:50 a.m. the resident had 2 more episodes of projectile vomiting. At 9:30 a.m. reflected the resident was transferred to the hospital per ambulance Review of the nurses' noted dated 7/19/10 at 5:00 p.m. reflected the resident returned to the facility with a [DIAGNOSES REDACTED]. Interview with S1DON on 10/27/10 at 1:45 p.m. confirmed on 7/19/10 the resident was transferred to the emergency room due to him projectile vomiting three times and having a 484 blood glucose level. The resident was diagnosed with [REDACTED]. Review of the nurses' notes reflected no documentation from 9/29/10 at 2:30 p.m. until 10/11/10. 10/11/10 5:30 a.m. nurses notes: resident #5 was found in bed breathing rapidly, cool to touch, stating "I feel bad all over", had projectile vomiting noted to be dark green in color, and was very weak. Further documentation of the resident's nurses' notes reflected a FSBS that was to high to register on the glucometer, a temperature of 99.1(ax), pulse - 114, respirations - 16 and blood pressure of 114/48. The nurses' notes reflected an order was received to send resident to the emergency room and the responsible party was notified and was "ok" with the resident being transferred. The nurses' notes on 10/11/10 at 5:55 a.m. revealed the resident went to the hospital per ambulance. Review of the Nursing Facility to Hospital Transfer form reflected on 10/11/10 at 5:55 a.m. the resident was transferred. Documentation for the reason for transfer/additional information reflected the resident was weak/lethargic, extremities were cold to touch. the resident complained of generalized pain and not feeling well, the FSBS was too high to register, and the resident had projectile vomiting. Further review of the transfer form reflected the resident's vital signs at 5:35 a.m. reflected the resident's Pulse 114, Respirations 16, Blood Pressure 114/48, Temperature 99.1(ax) and his O2Sat was 86% on room air. Phone interview with the S7LPN on 10/26/10 at 3:40 p.m. confirmed she worked 7:00 p.m. - 7:00 a.m. on 10/10/10 and was resident #5's nurse that night. S7LPN stated she had talked with the resident that night during med pass time and he took his medications without any problems. S7LPN stated the resident complained he did not feel good, but stated he said that every night. She also stated she did a walk through at 2:00 a.m. that morning to make sure all of her residents were breathing. Further interview with S7LPN revealed at 5:00 a.m. she started performing her morning blood glucose checks on her diabetic residents and arrived at the resident's room around 5:30 a.m. She stated she noticed upon entering the resident's room he wasn't breathing right and was cool to touch. She stated she noticed he must have projectile vomited because of where the vomit was located on his linens and he still had green vomitus on his teeth. S7LPN stated the resident was lying flat in bed and that was why she thought he must have projectile vomited. S7LPN stated she did not receive report from the nurse from the previous shift that the resident had vomited during the supper meal or that the resident was having any other problems. S7LPN also stated that she received no report during her shift that the resident had vomited until she noticed it upon entering the resident's room at 5:30 a.m. Interview on 10/26/10 at 3:50 p.m. with S3Adm. Assistant revealed that at around 5:30 p.m. on 10/10/10 she heard from her office, which was across the hall at any angle, a resident violently vomiting in the dining area. S3Adm. Assistant stated she went to the dining room and observed the resident vomiting and S4CNA trying to assist the resident in turning his head to the side to prevent him from vomiting on the other residents at the table. S3Adm. Assistant stated she went to the nurses station as S4CNA was wheeling the resident out of the dining room and told the staff that was in the nurses station the resident had just vomited. S3Adm. Assistant stated she was directly in front of S5LPN (the resident' nurse) when she reported the resident had vomited. S3Adm. Assistant stated S5LPN looked directly at her when she reported it. S3Adm. Assistant also revealed S8LPN was also in the nurses' station when she reported it. Phone interview with S5LPN on 10/28/10 at 10:25 a.m. stated she did not hear S3Adm. Assistant report that the resident had vomited in the dining room during the supper meal on 10/10/10. S5LPN confirmed she worked on 10/10/10 from 7:00 a.m. to 7:00 p.m. and that she received report that morning resident #5's blood sugar was elevated and he had received insulin per sliding scale as order at 6:00 a.m. S5LPN confirmed that she did not assess the resident or notify the resident's physician after he vomited because she did not know he had vomited. Interview with the S6Ward Clerk on 10/26/10 at 4:15 p.m. confirmed she was worked from 8:00 a.m. to 8:00 p.m. on 10/10/10 and was present when S3Adm. Assistant came to the nurses' station and reported to the resident's nurse that he had vomited in the dining room. S6Ward Clerk stated she asked S3Adm. Assistant what was that, because she had heard the resident vomit from the nurses' station. Review of an undated statement provided by the S1DON written by S8LPN reflected S8LPN heard S3Adm. Assistant ask the S6Ward Clerk to call for housekeeping to the dining room because resident #5 had thrown up. S3Adm. Assistant then told the hall nurse S5LPN that the resident had thrown up in the dining room and S5LPN then went down 300 hall (resident #5 was on the 400 hall) to do evening meds. Phone interview with S4CNA on 10/26/10 at 4:30 p.m. confirmed she worked from 2:00 p.m. to 6:00 a.m. on 10/10/10 to 10/11/10. S4CNA revealed she was passing out the supper meal trays when resident #5 began to vomit. S4CNA stated there were no nurses in the dining room at that time and she was trying to keep the resident from vomiting on other residents. S4CNA stated the vomiting was projectile. S4CNA confirmed S3Adm. Assistant came into the dining room when the resident was vomiting. S4CNA stated she took the resident to his room while S3Adm. Assistant went to the nurses' station and reported the resident had vomited. S4CNA confirmed that while she was in the resident's room no nurse came in and checked on him. Further interview with S4CNA confirmed the resident vomited again at approximately 7:30 p.m. to 8:00 p.m.. S4CNA stated she cleaned the resident up and reported to S7LPN that the resident had vomited again (2nd time). S4CNA stated S7LPN went to the resident's room. After interviewing the S4CNA, another phone interview was placed to S7LPN on 10/26/10 at 4:40 p.m., at which point she confirmed S4CNA had reported her that the resident had vomited around 7:30 - 8:00 p.m. and that she went to the resident's room to check on him. S7LPN confirmed she did not assess the resident's vital signs or his blood sugar. S7LPN confirmed she looked at resident and talked to him. S7LPN confirmed she did not document the resident's vomiting because she did not see any vomit. S7LPN confirmed she asked the resident how he was feeling and he stated that he felt bad all over, but did not look like he was in any distress and showed no signs that something was wrong. The S7LPN also confirmed that she did not notify the resident's physician until she found the resident lethargic, rapid breathing, had projectile vomited, O2Sat of 86% and complained of generalized pain. Review of the resident's Comprehensive Care Plan with a goal date of 11/10/10 reflected the resident had a problem with potential for Gastrointestinal upset with an approach that included to observe the resident for complaints of GI upset and report to the physician. Review of the facility's Change in Resident Medical Status policy reflected the facility must immediately consult with the resident's physician when a significant change in the resident's status occurs. Review of the facility's [MEDICAL CONDITION] Policy and Procedure reflected to assess the resident for early symptoms that included abdominal pain that can be rigid and have nausea and vomiting. Interview with the S1DON on 10/27/10 at 9:00 a.m. confirmed S5LPN and S7LPN both should have done an assessment of the resident, notified the resident's physician of the change in condition and documented it in the nurses' notes after the resident after had vomited. Further interview with the S1DON at that time confirmed the staff should have been aware that vomiting was a symptom of his [MEDICAL CONDITION]. Review of the hospital emergency room Record dated 10/11/10 at 6:44 a.m. reflected the resident's Clinical Impression was [MEDICAL CONDITION]. Review of the Lab Summary of a Chemistry drawn at 7:04 a.m. reflected the resident's Glucose level was 977. Review of the CXR Impression dated 10/11/10 at 7:43 a.m. reflected a suggestion of small Left Pleural effusion and probable Left Lower Lobe Infiltrate or Atelectasis.