Every finding on record at Green Country Care Center

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 03/10/26 at 4:00 a.m. related to the facility's failure to ensure a resident with moderately impaired cognition and history of elopement did not elope unnoticed from the facility.On 03/19/26, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to prevent a resident's elopement.The past noncompliance IJ was removed effective 03/10/26 at 1:30 p.m., when the facility had put the following measures in place to prevent recurrence.a. On 03/10/26 the administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of Res #1 until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.b. On 03/10/26 the maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building. They also checked to ensure each window remained locked and secure from being opened by residents. c. On 03/10/26 at 9:36 a.m. the resident was placed on 1:1 monitoring for high elopement risk.d. On 03/10/26 at 1:30 p.m. the facility completed mandatory staff training on elopement prevention for a 31 staff. Staff participation was verified through training sign in sheets and interviews. Based on record review and interview, the facility failed to ensure a resident did not elope from the facility for 1 (#1) of 3 sampled residents reviewed for elopement.The administrator stated that 81 residents resided at the facility.Findings:An undated facility policy, titled, Elopements, showed the facility had a five-point plan regarding elopement prevention, reporting, searching, and care of residents after return to the facility.A face sheet from a community acute care hospital, dated 02/20/26, showed the hospital had sent Res #1 to a nursing facility where they quickly eloped. The document further showed the nursing facility then refused to accept the resident and sent Res #1 back to the hospital.A social services admission evaluation, dated 03/04/26, showed a family member had stated they were happy Res #1 was in a locked memory care facility as they were an elopement risk.An incident report form (ODH form 283), incident date 03/10/26, showed that on 03/10/26 at approximately 6:20 a.m., facility staff discovered they could not locate Res #1. The incident report further showed that at approximately 8:40 a.m., Res #1 was found in the community near a local public school (the school is located approximately 2.2 miles from the facility).An admission assessment, dated 03/11/26, showed Res #1 had been admitted to the facility on [DATE] with diagnoses which included non-traumatic brain disfunction and dementia. The resident's BIMS (a test of cognitive functioning) score of 9 showed the residents' cognition was moderately impaired.On 03/18/26 at 10:33 a.m., family member #1 stated Res #1 had previously eloped from another nursing home prior to being admitted to the facility. They stated the resident had memory problems stemming from a motor vehicle accident. They also stated in another incident Res #1 had been hit by a car while walking in the community. Family Member #1 stated they had made staff aware of the resident's history during the admission process.On 03/19/26 at 8:17 a.m., LPN #1 stated they had found out about Res #1 being missing from LPN #2 on 03/10/26 at 8:00 a.m. They stated the resident was returned to the facility by a staff member later in the morning at about 9:30 a.m. LPN #1 stated they assessed the resident when they returned and found no injuries.On 03/19/26 at 8:46 a.m., CNA #1 stated they had clocked into work at approximately 6:52 a.m. and just prior to 7:00 a.m., they went to Res #1's room. They stated they did not find the resident in their room, and they and LPN #2 searched the building and surrounding area but did not locate the resident. CNA #1 stated they had gone back to Res #1's room to check again. They stated when they checked the window it was still secured and the window screen was in place. They stated they did not know how the resident got out of the building.On 03/19/26 at 11:18 a.m., CNA #2 stated the last time they had observed Res #1 on 03/10/26 was at approximately 4:00 a.m., during their last rounds of the night shift.On 03/19/26 at 11:25 a.m., LPN #3 stated the last time they observed Res #1 on 03/10/26 was approximately 3:30 a.m. during the night shift.On 03/19/26 at 1:24 p.m., the SW stated during admission they did not hear about the resident's elopement history from Res #1's family but from later reading hospital records. They stated the day after learning of the elopement history they had informed the nursing staff during the morning meeting. They stated they had not documented learning about the elopement history or that they had alerted the staff but was sure they would have notified staff. On 03/19/26 at 1:50 p.m., the administrator stated they had not been able to definitely identify how Res #1 had eloped from the facility, but they had taken steps to ensure the staff was vigilant in regards to resident safety. They stated they had ensured that all exits would continue to be inspected with resident security and safety in mind.

Based on record review and interview, the facility failed to ensure a resident or their legal representative received education regarding the benefits and potential side effects of the influenza immunization and obtain consent before administering the immunization for 1 (#4) of 3 sampled residents reviewed for immunizations. The administrator identified 74 residents resided in the facility Findings: A facility policy titled Vaccination of Residents, revised 08/2016, read in part, Prior to receiving vaccinations the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccination .The residents legal representative may refuse vaccines for any reasons. Resident #4 was admitted on [DATE] with diagnoses which included dementia and anxiety. An annual MDS assessment, dated 01/24/25, showed the resident's cognition was severely impaired with a brief interview for mental status score of 99. A review of Resident #4's profile sheet showed family member #1 as the resident's POA. On 03/25/25 at 11:30 a.m., family member #1 stated in 2023 they had informed a nurse at the facility they did not wish for the resident to receive any further vaccines of any kind. Family Member #1 stated during a care plan meeting in October of 2024 they were informed the resident had received a flu vaccine the previous day. Family Member #1 stated no one from the facility had called them to obtain consent before the vaccine was given. On 03/25/25 at 12:50 p.m., the DON stated Resident #4 did receive a flu vaccine in October of 2024. The DON stated in 2023 the resident's POA had informed the MDS nurse the resident was not to receive any further vaccines of any kind, but they failed to document it in the resident's record or inform anyone.

Based on observation and interview, the facility failed to provide access to notifications of resident rights, ombudsman contact information, and state agency contact information. The administrator identified 76 residents resided in the facility. Findings: On 11/13/24 at 10:41 a.m., the five residents who attended the resident council meeting stated they did not know where to find the phone number to contact the ombudsman, did not know where the resident rights were posted, or how to contact OSDH to register a complaint or concern. Immediately following the resident council meeting, the notices were observed to be posted in the locked vestibule by the facility front door, and inside the nurses' station along the far wall. The locked vestibule was not accessible by the residents. The notices inside the nurses' station were not readable from the hallway. On 11/13/24 at 11:41 a.m., the administrator stated the ombudsman's phone number, resident rights, and state department phone numbers were posted in the vestibule and by the back nurses' station. The administrator stated the information in the vestibule was not accessible by residents, but was visible for family. The administrator stated residents were not permitted inside the nurses' station and the notices were not readable from outside the nurses station.

Based on record review and interview, the facility failed to provide information to formulate an advance directive for three (#22, 66, and #71) of three sampled residents who were reviewed for advance directives. The administrator identified 75 residents who resided in the facility. Findings: The Advance Directives policy, dated December 2016, read in part, Upon admission, the resident will be provided with written information concerning the right .to formulate an advance directive if he or she chooses to do so .the information may be provided to the resident's legal representative .The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. 1. Resident #22 was admitted to the facility on [DATE]. No acknowledgement form for an advance directive was in the resident's electronic record. 2. Resident #71 was admitted to the facility on [DATE]. No acknowledgement form for an advance directive was in the resident's electronic record. On 11/14/24 at 11:45 a.m., the admissions coordinator stated they did not have documentation an advance directive was offered to Resident #22 and Resident #71. 35474 3. Resident #66 had diagnoses which included dementia. Review of the electronic clinical record documented the resident was a full code status. Documentation of information provided to the resident/resident representative for formulation of an advance directive was not available in the electronic clinical record. On 11/14/24 at 11:41 a.m., the admissions coordinator stated they were unaware they needed to document that residents had been offered advance directives. They stated the family for Resident #66 wanted the resident's code status to be a full code, but discussion regarding the formulation of an advance directive had not been documented. On 11/15/24 at 10:11 a.m., the administrator stated the admission packet contained information for the resident/resident representative regarding formulating an advance directive. On 11/15/24 at 10:18 a.m., the administrator stated they did not have documentation an advance directive had been discussed with Resident #66 or their representative.

Based on observation, record review, and interview, the facility failed to ensure medications were dated when opened for one (North hall medication cart) of two medication carts observed. The DON identified four medication carts in the facility. Findings: On 11/15/24 at 3:56 p.m., the North hall medication cart was observed with LPN #1. The following medications were observed to be open, but not dated. a. neomycin/polymyxin 0.1% eye drops for Resident #126; b. fluticasone nasal spray 50mcg for Resident #47; c. fluticasone nasal spray 50mcg for Resident #11; and d. fluticasone nasal spray 50mcg for Resident #14. On 11/15/24 at 3:58 p.m., LPN #1 stated they were to date nasal sprays and eye drops when they were opened. On 11/15/24 at 4:21 p.m., the DON stated they were to date nasal sprays and eye drops when they were opened.

Based on observation and interview, the facilty failed to ensure infection control was maintained during feeding assistance for one (#55) of one sampled resident observed for meal assistance. The administrator identified 20 residents dependent on staff for meal assistance. Findings: On 11/12/24 at 12:09 p.m., LPN #1 was observed assisting Resident #55 with the noon meal. LPN #1 was observed to blow on a spoonful of food before placing it in Resident #55's mouth. On 11/12/24 at 12:12 p.m., LPN #1 stated to maintain infection control they should not blow on a resident's food. On 11/15/24 at 4:30 p.m., the DON stated if food was hot the staff were to let it cool down before feeding it to residents. The DON stated staff should not blow on residents' food.

Based on record review and interview, the facility failed to ensure advance beneficiary notices had been provided for two (#22 and #47) of three sampled residents reviewed for beneficiary notices. The Entrance Conference Worksheet documented ten residents who remained in the facility with skilled days remaining in the past six months. Findings: 1. Resident #22 had diagnoses which included dementia. The SNF Beneficiary Notification Review form, completed by the facility, documented the resident's last covered day of Part A services was 06/13/24, the facility initiated the discharge from skilled services, and an ABN had not been provided. The undated NOMNC, provided by the facility, documented the resident/resident representative had been notified of the change in services on 06/12/24. Review of the electronic clinical record revealed the resident remained in the facility long term care after skilled services had ended. 2. Resident #47 had diagnoses which included dementia. The SNF Beneficiary Notification Review form, completed by the facility, documented the resident's last covered day of Part A services was 08/29/24, the facility initiated the discharge from skilled services, and an ABN had not been provided. The undated NOMNC, provided by the facility, documented the resident/resident representative had been notified of the change in services on 08/29/24. Review of the electronic clinical record revealed the resident remained in the facility for long term care after skilled services had ended. On 11/15/24 at 10:06 a.m., the admissions coordinator stated they only provided the NOMNC when residents were discharged from skilled services. They stated they were notified to make the resident/resident representative aware of the change in services 48 hours in advance. They stated they had verbally notified the representatives for both Resident #22 and Resident #47, but had not documented the notification. On 11/15/24 at 10:10 a.m., the administrator stated the facility had missed providing the ABNs and training was needed for beneficiary notices.

Based on record review and interview, the facility failed to ensure assessments were encoded and transmitted for one (#128) of one sampled resident reviewed for assessments. The administrator identified 76 residents who resided in the facility. Findings: Resident #128 had diagnoses which included dementia. A discharge return anticipated assessment, dated 09/10/24, documented the resident had discharged from the facility. A progress note, dated 09/11/24, documented the resident had returned from the hospital. Review of the assessments in the electronic clinical record did not reveal an entry assessment had been completed upon the resident's readmission to the facility on [DATE]. The next documented assessment in the electronic clinical record, after the discharge return anticipated assessment, was an in progress quarterly assessment dated [DATE]. On 11/15/24 at 2:03 p.m., MDS coordinator #1 stated they completed an entry assessment when a resident returned from a hospital stay. They stated the entry assessment for 09/11/24, for Resident #128, had been overlooked. On 11/15/24 at 3:21 p.m., MDS coordinator #2 stated they had reviewed the assessments for Resident #128 and noted the entry assessment for 09/11/24 had not been completed. They stated the assessment had been overlooked. They stated they utilized a tracking form to monitor discharge assessments, but did not monitor for entry/re-entry assessment completion.

Based on observation, record review, and interview, the facility failed to update the care plan for two (#22 and #128) of two sampled residents whose care plans were reviewed. The administrator identified 76 residents resided in the facility. Findings: 1. Resident #22 had diagnoses which included dementia. A Care Plan, dated 09/05/24, documented no care areas related to skin picking. On 11/12/24 at 8:59 a.m., Resident #22 was observed with a nickel size open wound on the right side of the back of their neck and multiple small wounds on their forehead and hands. On 11/14/24 at 2:19 p.m., LPN #2 stated the resident has several places on their face and hands where they picked the skin open. LPN #2 stated the wounds scabbed over and the resident opened them again. LPN #2 stated the resident had always done this. A review of the resident's care plan did not reveal an update to include the resident picking at their skin. On 11/14/24 at 3:12 p.m., MDS Coordinator #1 stated they had updated the resident's care plan on 11/14/24, but had not included picking at the skin prior to 11/14/24. 35474 2. Resident #128 had diagnoses which included dementia. The quarterly assessment, dated 08/20/24, documented the resident rejected care one to three days during the look back period. The discharge return anticipated assessment, dated 09/10/24, documented the resident required supervision/touch assist for bathing and toileting. The assessment documented the resident rejected care one to three days during the look back period. The CNA Shower Skin Observation Tool forms, dated 10/02/24 through 11/15/24, documented the resident had refused showers 17 times out of 22 opportunities. On 11/13/24 at 11:35 a.m., the resident was observed sitting on their bed. A urine/body odor was observed upon entering the resident's room. The Care Plan, revised 11/14/24, documented to assist the resident with bathing as needed. The care plan did not document the resident refused showers or care. On 11/14/24 at 8:54 a.m., the resident was observed sitting on their bed. A urine odor was observed upon entering the resident's room. On 11/15/24 at 11:12 a.m., CNA #1 stated the resident had a history of refusing care such as showers and linen changes. On 11/15/24 at 12:51 a.m., the DON stated the resident refused showers and incontinent care at times. On 11/15/24 at 1:03 p.m., the ADON stated the resident refused showers. They stated they would try different staff, different shifts, and call the resident's family for assistance. On 11/15/24 at 4:09 p.m., MDS coordinator #1 stated they were not aware the resident refused care such as showers. They stated they had not seen documentation of refusals. On 11/15/24 at 4:11 p.m., MDS coordinator #2 stated they had not been made aware the resident refused showers so they had not updated the care plan related to the refusal of care for Resident #128.

Based on observation, record review, and interview, the facility failed to ensure showers to dependent residents for one (#128) of one sampled resident who was reviewed for ADL care. The DON identified 62 residents who were dependent on staff for bathing. Findings: Resident #128 had diagnoses which included dementia. The quarterly assessment, dated 08/20/24, documented the resident required set up assistance for showers and rejected care one to three days during the look back period. The discharge return anticipated assessment, dated 09/10/24, documented the resident required supervision/touch assist for bathing and toileting. The assessment documented the resident rejected care one to three days during the look back period. The CNA Shower Skin Observation Tool forms, dated 10/02/24 through 11/15/24, documented the resident had refused showers 17 times out of 22 opportunities. The form documented, Refused? Intervention to prevent recurrence? The area for documentation of intervention to prevent recurrence was left blank on all 17 documented refused showers. On 11/13/24 at 11:35 a.m., the resident was observed sitting on their bed. A urine/body odor was observed upon entering the resident's room. The Care Plan, revised 11/14/24, documented to assist the resident with bathing as needed. The care plan did not document the resident refused showers or care. On 11/14/24 at 8:54 a.m., the resident was observed sitting on their bed. A urine/body odor was observed upon entering the resident's room. On 11/15/24 at 11:12 a.m., CNA #1 stated the resident had a history of refusing care such as showers and linen changes. CNA #1 stated the odor in the resident's room was because at times the resident urinated near, but not in the toilet, the resident refused showers, and refused linen changes. CNA #1 stated at times they would call the resident's family member for assistance with ADL care. On 11/15/24 at 12:51 a.m., the DON stated the resident wanted to be more independent than possible due to a visual impairment. The DON stated the resident refused showers and incontinent care and they notified the family for assistance. On 11/15/24 at 1:03 p.m., the ADON stated the resident refused showers. They stated they would try different staff, different shifts, and call the resident's family for assistance. On 11/15/24 at 4:21 p.m., the DON stated they were not aware Resident #128 had refused as many showers as they had since 10/02/24. The DON stated the ADON was responsible to monitor the hall the resident resided on to ensure ADL care had been received. On 11/15/24 at 4:41 p.m., the ADON stated the charge nurse and themselves were responsible to review the shower sheets to ensure residents were receiving ADL assistance. They stated if refusals were documented on the shower sheet interventions would need to be implemented.

Based on observation and interview, the facility failed to ensure staff used proper hand hygiene when serving meals and assisting residents to eat in the dining room. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: On 09/25/23 at 12:13 p.m., CNA #1 and CNA #2 were observed touching the rim of the drinking glasses and dessert cups while delivering the residents' meals. On 09/25/23 at 12:17 p.m., CNA #3 was observed to move a resident wheelchair up to a table and then, without first performing hand hygiene, touched the residents drinking glasses by the rim when placing them on the table. On 09/25/23 at 12:22 p.m., CNA #4 was assisting two residents in the dining room to eat at the same time. CNA #4 was observed to give a bite of food to one resident and then give a bite of food to a second resident. The CNA was not observed to use hand hygiene during this observation. On 09/25/23 at 12:24 p.m., CNA #2 was observed to place a clothing protector on a resident and then take a dirty tray to the window pass on the dish machine side of the dining room. CNA #2 then moved a chair by the chair arms, sat down to assist a resident with a bite of food, then moved the chair around the table to another resident, and gave another resident a bite of food. CNA #2 was then observed to go all the way around the table by moving the chair and assisting all four residents at the table with eating their food. Hand hygiene was not performed by the CNA during the observation. On 09/25/23 at 12:29 p.m., CNA #2 was observed to move the bread on a residents plate off the plate and onto a napkin with their bare hand. Hand hygiene was not observed. On 09/25/23 at 12:30 p.m., CMA #1 was observed to move a chair to the table where CNA #2 was assisting resident to eat and started to assist two of the four residents with their meals. Hand hygiene was not observed before the CMA started assisting the residents. The CMA was observed to touch one of the residents on the resident's clothing while trying to get the resident to eat. The CMA then assisted the other resident with their meal. Hand hygiene was not observed to have been performed between residents. On 09/25/23 at 12:36 p.m., CNA #1 was observed feeding two residents by alternating bites of food between the residents without performing hand hygiene between residents. On 09/25/23 at 12:37 p.m., LPN # 3 was observed to open the door to the dining room with a code to let residents out of the dining room then returned to assisting two resident to eat. Hand hygiene was not observed before restarting to feed the residents or between residents. On 09/25/23 at 12:41 p.m., CNA #2 was observed to wipe their forehead and then continue to assist a resident eat their meal. Hand hygiene was not observed. On 09/25/23 at 12:42 p.m., CNA #3 was observed to stand and assist a resident with a bite of food then returned to assisting another resident to eat their meal. Hand hygiene was not observed. On 09/27/23 at 10:49 a.m. CNA #3 stated hand hygiene should have been done every time your assist a resident to eat. The CNA stated when feeding more than one resident they should have performed hand hygiene between residents. On 09/27/23 at 12:27 p.m., the DON stated the staff should not have touched the rims of the drinking glasses. The DON stated hand hygiene should have been performed after a tray was passed and hand hygiene should have been performed between residents when assisting more than one resident to eat. The DON stated moving from one resident to another resident would not have been not be appropriate without first performing hand hygiene.

Based on record review and interview the facility failed to act upon a dietitian recommendation timely for one (#50) of four sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: Res #50 had diagnoses which included other specified eating disorder, diabetes mellitus, and dementia. The EHR documented,on 02/01/22, the resident's weight was 221.8 lbs. A dietitian note, dated 05/28/23, documented the resident's weight was 183.2 pounds. The note documented the resident's weight was down 7.8% in two months and down 14.6% in four months. The resident weight was trending down but their BMI was 32.4. The note documented the resident chews on non-edible items frequently and wanders frequently. The note documented the resident eats 76-100% of a puree diet with 2 eggs and nectar liquids and was fed by staff at times. The resident intake of shakes with meals had decreased in May with intake approximately 50%. The dietitian documented they recommended to start 2 oz of Med Pass with medications TID. A dietitian note, dated 06/29/23, documented the resident weighed 180 lbs. The note documented the resident's weight was down 16% in six months and the resident's BMI was still 31.9, but weight continued to trend down. The resident was eating 76-100% of a puree diet with two eggs at breakfast. The resident's intake of shakes with meals was fair to poor. The resident was active with wandering. The note documented the dietitian recommended 2 oz Med Pass TID with medications. A physician order, dated 08/02/23, documented Med Pass TID a day give 2 oz three times a day for a supplement. An annual assessment, dated 08/17/23, documented the resident was severely impaired with cognition, weighed 167 lbs, and had not had a weight loss. A care plan, last revised 09/01/23, documented the resident's weight was slowly trending down but remained above their ideal body weight range. The care plan documented to weigh and provide supplements as the physician ordered. On 09/10/23, the resident weight was documented at 161.2 pounds which was a -27.32 % weight loss in six months. On 09/27/23 at 3:15 p.m., the DM stated the dietitian came to the facility monthly and would documented on the residents with weight loss. On 09/27/23 at 3:59 p.m., the DON stated they got the recommendations from the dietitian and they have to notify the physician. The DON stated they normally get the information in a couple of days after the dietitian was in the facility. The DON stated from May to August was to long for the recommendation of Med Pass to not have been acted upon. On 09/27/23 at 4:21 p.m., the dietitian stated if they did not see an improvement in the resident's weight they would request an increase in the Med Pass. On 09/27/23 at 4:22 p.m., MDS Coordinator #2 stated when they calculated the residents weight it did not calculate a weight loss. MDS coordinator #2 stated they were going to go calculate and let the surveyor know if a weight loss should have been documented on the MDS in August. On 09/27/23 at 5:12 p.m., MDS coordinator #2 stated the resident did have an significant weight loss and it was not captured on the MDS in August. She stated the resident was not on a physician prescribed weight loss program.

Based on observation and interview, the facility failed to ensure resident dignity related to: a. Res #50 was not disrobe and/or expose themselves in front of other residents and staff in the dining room and on the unit; b. the residents on the locked unit had on proper foot-wear when in the dining room and on the unit; and c. staff did not stand while assisting residents to eat. The Resident Census and Condition of Residents form documented 79 residents who resided in the facility. Findings: 1. Res #50 had diagnoses which included frontotemporal neurocognitive disorder and dementia. An annual assessment, dated 08/17/23, documented the resident was severely impaired with cognition and required limited to extensive assistance with ADLs. The care plan, last revised 09/01/23, did not document a behavior of disrobing, exposing self, or wandering. On 09/25/23 at 12:45 p.m., the resident was observed in the dining room with a pink and gray pajama set on which was unzipped to the residents waist, exposing the resident's breasts and stomach. CNA #2 got up from assisting residents to eat wiped food from the front of the resident and zipped up the resident's pajamas. The CNA then opened the locked door and let the resident out of the dining room onto the unit hallway. On 09/25/23 at approximately 1:30 p.m., Res #50 was observed sitting in a chair in room [ROOM NUMBER], which was not the resident's room, with their pajamas unzipped to their waist exposing their breasts. Several other unidentified residents were observed in room [ROOM NUMBER] at that time. Res #50 then came out of room [ROOM NUMBER] while still unzipped and walked down the hall to a door at the end of the hall with a male resident. Staff members were observed in the hallway near the door and did not stop the resident or zip up the resident's clothing. On 09/27/23 at 12:21 p.m., the DON stated Res #50 would lift shirts up or unzip their clothing and expose themselves in the process. The DON stated the staff dressed the resident in clothing which made it more difficult for them to undress and expose themselves. The DON confirmed this was not a normal behavior for a reasonable person and the staff should have ensured the resident was covered and/or dressed appropriately when in public areas or when with other residents. On 09/28/23 at 8:38 a.m., Res #50 was observed in the living area of the locked unit rocking back and forth in a recliner. The resident had on a jump suit night outfit that zipped up from the lower abdomen upward. The resident was observed with the jump suit unzipped and left breast was exposed. A total of 18 residents,including Res #50, were observed in the living area. On 09/28/23 at 11:08 a.m., the resident was observed with the purple jumpsuit on backwards with the zipper in the back where the resident could not unzip the clothing. Res #50 standing at the nurses station pushing empty medication cups up and down the counter. The resident was unable to be interviewed. 2. On 09/25/23 at 12:00 p.m., there were approximately 10 residents observed in the locked unit's dining room without any foot coverings on their feet. On 09/25/23 at 12:26 p.m., CNA #4 was observed to stand and assist one of the residents with a bite of food. On 09/25/23 at 12:42 p.m., CNA #3 was observed to stand and assist a resident with a bite of food then returned to assisting another resident to eat. On 09/27/23 at 10:49 a.m., CNA #3 stated when assisting residents to eat they should have sat down. On 09/27/23 at 12:27 p.m., the DON stated the staff should be at eye level, not standing, when assisting residents to eat. The DON stated foot-wear of some sort should have been on the residents when on the unit, hallways, and when in the dining room.

Based on observation, record review, and interview, the facility failed to ensure residents received the supervision and assistance to prevent falls for one (#31) of three sampled residents reviewed for falls. The Resident Census and Conditions of Residents form, documented 79 residents resided at the facility. Findings: Res #31 had diagnoses which included epilepsy, weakness, and unsteadiness on feet. A quarterly assessment, dated 06/12/23, documented the resident was moderately impaired with cognition and required extensive assistance with most ADLs. The assessment documented the resident had two injury falls since admission or last assessment. An incident report, dated 03/23/23, documented a non injury fall and the resident was found on the floor in the door way of the bathroom. The incident report documented they were exiting the bathroom and slipped and fell to the floor due to the floor being wet. The care plan intervention dated 03/23/23, documented to remind the resident to call for help with safety concerns when needed. An incident report, dated 06/09/23, documented a non injury fall. The report documented the resident was observed sitting on the floor in their room. The resident stated they had fallen to the floor walking to the bathroom. The incident report documented the resident had a small skin tear to the left ring finger. The care plan intervention, dated 06/09/23, documented to offer the resident toileting before an after meals. An incident report, dated 06/15/23, documented a non injury fall. The report documented the resident was observed in the bathroom laying on the floor between the sink and toilet. The resident stated they turned to get on the toilet and fell . The resident reported they were not hurt and did not hit their head. The care plan intervention dated 06/15/23, documented after the evening meal encourage resident to try and use the bathroom. An incident report, dated 07/03/23, documented the resident was seen ambulation down the hall way with blood on their right hand. A skin tear was observed to the residents right hand with no other physical injuries. The report documented the report documented steri strips applied to skin tear. The care plan did not contain an intervention for the fall dated 07/03/23. An incident report, dated 7/24/23, documented the resident was observed walking up to nurse desk looking for their wheelchair, blood leaking from their outer right hand. The report documented three skin tears were observed. The incident report documented the resident reported they fell in their room earlier in the day. The resident could not explain how they fell . The skin tears were cleaned and steri stripped. The care plan intervention, dated 07/24/23, documented an intervention of after the lunch meal staff were to check with the resident to address any needs or wants or any level of assistance needed. An incident report, dated 09/03/23, documented the nurse was made aware of resident on the floor in personal room by a CNA. The CNA described the resident finger looked broken. Upon arrival to the resident's room, this nurse observed resident holding left arm up towards the nurse. The resident verbalized they fell down. The incident report documented the resident was awake and alert with no signs or symptoms of pain or discomfort noted. The incident note documented It appeared the resident had a dislocated finger no open area or blood observed. The report documented the resident was sent to the hospital for treatment. The care plan intervention, for 09/03/23, documented an intervention of staff were to remind resident throughout the day to seek assistance for any needs or wants and the resident went to the ER for evaluation and treatment. On 09/26/23 at 10:47 a.m., Res #31 stated they fell and hurt their fingers. Res #31 stated they did not remember what they were doing when they fell . Res #31 was able to move all their finger without pain. On 09/28/23 at 1:12 p.m., MDS Coordinator #2 stated they were not seeing an intervention for the 07/03/23 fall an that it could have been overlooked.

Based on observation and interview, the facility failed to ensure a physician order for Tuba grips was followed for one (#31) of one sampled resident for edema. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: Res #31 had diagnoses which included inflammatory and immune myopathies, pain, and swelling. A physician order, dated 03/09/23, documented Tuba grips two times a day for pain and swelling. A quarterly assessment, dated 06/12/23, documented the resident was moderately impaired with cognition and required extensive assistance with most ADLs. A care plan, last reviewed 07/25/23, documented the resident had edema. The care plan documented to administer medication as ordered. The care plan did not documented the resident was to have Tuba grips. On 09/26/23 at 10:53 a.m., Res #31's feet were observed swollen and the resident stated look how swollen my feet are. On 09/28/23 at 12:14 p.m., Res #31 was observed sitting in the living room in front of the TV. He had on gray ankle socks at this time. On 09/28/23 at 1:45 p.m., Res #31 was observed in their wheelchair with regular socks on their feet. The resident stated their feet were really swollen and the staff forget to put the socks on for swelling of his feet. On 09/28/23 at 1:51 p.m., LPN #1 was observed at the nurse station. LPN #1 stated the resident had removed the tuba grips and threw them away. The LPN stated they had put them on the resident. On 09/28/23 at 2:22 p.m., there was no documentation in the nurse notes that the resident had removed his tuba grips and threw them away. On 09/28/23 at 2:31 p.m., Res #31 stated they did not remove any socks and throw them away. Res #31 then asked if the staff were going to put the tuba grips on today. On 09/28/23 at 2:34 p.m., LPN #2 stated they normally take the tuba grips off before the resident goes to bed at night. On 09/28/23 at 2:36 p.m., LPN #2 observed the resident in their room and stated the resident did not have the tuba grips on at this time. LPN #2 stated they would get some and put them on the resident. LPN #2 looked on the unit for some and then left the unit at 2:38 p.m., and returned to the unit with the tuba grips and placed them on the resident. On 09/28/23 at 2:44 p.m., LPN #2 stated they did not have any tuba grips on the unit and had to go get some for the resident.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed and/or implemented to address the residents' needs related to a wandering and behavior care plan for one (#50); and the use of a broda chair for one (#60) of 18 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 79 residents resided in the facility. Findings: 1. Res #50 had diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An annual assessment, dated 08/17/23, documented the resident was severely impaired with cognition and required limited to extensive assistance with most ADLs. The assessment documented the resident received antianxiety and antidepressant medication. A care plan, last revised 09/01/23, did not documented Res #50's behaviors of taking of their clothing and eating non eatable items. On 09/25/23 at 12:45 p.m., the resident was observed in the dining room with a pink and gray pajama set on which was unzipped to her waist. The resident was exposed showing their breasts and stomach. On 09/27/23 at 2:40 p.m., MDS Coordinator #2 stated the resident's behaviors should have been documented in the EHR and that would be where they would find the behaviors. MDS Coordinator #2 stated the behaviors of the resident for wandering and disrobing should have been care planned but there had been no documentation of the resident having the behaviors documented. 46909 2. Res #60 was admitted to the facility with diagnoses of Alzheimer's disease, psychotic disorder with delusions, psuedobulbar affect, and insomnia. An admission assessment, dated 06/30/23, documented the resident had short and long term memory problems and required extensive assistance with all ADLS. An incident report dated 08/13/23 documented the resident was found on the floor next to his low positioned bed. An incident report dated 08/13/23 documented the resident fell from their chair onto the floor. An incident report dated 09/14/23 documented the resident was on the floor next to his bed. On 09/27/23, the resident was observed sitting in a Broda chair in the common area with other residents. On 09/27/23 at 1:13 p.m., an interview was conducted with LPN #3 and they stated the resident was placed in the Broad chair to prevent the resident from falling. On 09/27/23 at 1:13 p.m., an interview was conducted with the DON and they stated the family bought the Broda chair for the resident to keep the resident from falling out of another chair. The Broda chair was not added to the resident's care plan.

Based on record review and interview, the facility failed to ensure the OHCA was notified of residents with serious mental illness for one (#63) of two sampled residents reviewed for PASRR evaluations. The Resident Census and Conditions of Residents report documented 32 residents had documented psychiatric diagnosis. Findings: Res #63 was admitted on [DATE] with diagnose which included psychotic disorder with delusions due to known physiological condition, recurrent depressive disorders, anxiety disorder, and insomnia. A PASRR I dated 01/29/23 documented the resident had a diagnoses of Psychotic disorder with delusions. The PASRR documented the resident did not have a serious mental illness. An admission assessment, dated 02/09/23, documented no PASRR level II. The assessment documented the resident was moderately impaired with cognition and had no behaviors. A physician order, dated 09/22/23, documented buspirone (an antianxiety medication) administer twice a day related to unspecified dementia, moderate, with agitation. On 09/27/23 at 4:53 p.m., MDS coordinator #1 stated they did not contact OHCA related to the same thing they were saying before, its related to the resident having dementia. MDS coordinator #1 stated their rational was they had been educated when a resident had dementia they did not contact OCHA. MDS coordinator #1 stated they had not questioned the diagnosis for the resident's Buspar. The MDS coordinator #1 stated they did not typically put medications in and the nurse do not call them and give them the diagnoses that go with the medication.

Based on record review and interview, the facility failed to ensure the state was notified of a new serious mental illness for one (#50) of two sampled resident reviewed for PASRR. The Resident Census and Conditions of Residents report documented 32 residents had documented psychiatric diagnosis. Findings: Res #50 was admitted to the facility on [DATE] and had diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A PASRR I, dated 08/12/19, documented the questions for mental illness were marked as no. On 02/24/20, the resident received a new diagnoses of unspecified psychosis not due to a substance of known physiological condition. An annual assessment, dated 08/17/23, documented the resident did not have a PASRR II, was severely impaired with cognition and limited to extensive assistance with most ADLs. The assessment documented the resident received and antianxiety and an antidepressant medication seven day in the look back period. A care plan, last revised 09/01/23, documented Res #50's PASRR recommendations were to follow Oklahoma Healthcare Authority recommendations, and Res #50's recommendation was a level one. On 09/27/23 at 1:57 p.m., MDS coordinator #1 stated when a resident had an underlying dementia diagnosis, they did not have to call the OHCA. MDS coordinator #1 stated she had been educated on when to request a level II PASRR and it depended on what diagnosis came first. The MDS coordinator stated they would ask family if the resident had past psychatric diagnoses. MDS coordinator #1 stated the PASRR for Res #50 was completed before she worked at the facility. On 09/27/23 at 2:14 p.m., MDS coordinator #2 stated when the primary diagnosis was dementia, they did not call when a resident received a new mental health diagnoses. MDS coordinator #2 stated a level II PASRR was not needed for Res #50. MDS coordinator #2 stated if they had called OHCA it would have been documented on the form and it was not.

Based on record review and interview, the facility failed to ensure a significant change assessment was completed when a resident had a decline in two or more areas of ADLs for one (#62) of 20 sampled residents reviewed for assessments. The Resident Census and Conditions of Residents report, dated 09/25/23, documented 79 residents resided in the facility. Findings: Res #62 had diagnoses which included Alzheimer's disease, vascular dementia, HTN, hyperlipidemia, DM, heart disease, GERD, anxiety, depression, chronic pain, and adult failure to thrive, A quarterly assessment, dated 04/06/23, documented the resident required limited assistance with dressing and was frequently incontinent of bladder and bowel. A quarterly assessment, dated 07/07/23, documented the resident required extensive assistance with dressing and was always incontinent of bladder and bowel. On 09/28/23 at 1:45 p.m., MDS Coordinator #2 stated a decline in two or more areas of ADLs constituted a significant change assessment. They were asked to compare the April and July quarterly assessments. They stated they could see where the the July assessment could have been a significant change assessment.

Based on record review and interview, the facility failed to ensure an Oklahoma DNR consent form was dated for one (#60) of one resident reviewed for advance directives. The Resident Census and Condition of Residents form documented 79 residents who reside in the facility. Findings: Res #60 was admitted to the facility on [DATE] and had diagnoses which included DM, hypothyroidism, depressive disorder, and dementia with severe mood disturbances. The care plan, dated 03/03/23, documented the resident had a DNR status. A quarterly assessment, dated 08/26/23, documented the resident was moderately impaired with cognition and was independent with most of their ADLs. An Oklahoma DNR consent form was present in the resident's EHR. The consent form was signed by the resident's POA, but was not dated. On 09/27/23 at 5:45 p.m., the administrator stated the DNR consent form was signed by the POA but was not dated. They stated it just slipped through the cracks. The administrator stated they would call the POA and they would correct the DNR.

Based on observation, interview, and record review, it was determined the facility failed to ensure parameters were identified and a physician was notified regarding a resident who was symptomatic with low blood sugars to ensure the resident received appropriate treatment for [REDACTED].#28) of seven sampled residents. The facility identified 22 residents who had a [DIAGNOSES REDACTED]. The physician was not notified. The resident experienced another episode of [DIAGNOSES REDACTED] that required an emergent transfer and admission to the hospital on [DATE]. Findings: Resident #28 had [DIAGNOSES REDACTED]. An annual assessment, dated 10/26/18, documented the resident was severely cognitively impaired, required extensive assistance with most activities of daily living, and had received insulin seven days out of the seven day look back period. A care plan, initiated on 11/02/18, documented: .I have a dx of Dabetes Mellitus . Goal I will have no complications related to diabetes through the review date . Interventions Adjust meds per physician order [REDACTED].>Check my body for breaks in skin during care and report to nurse . Enc. (encourage) me to avoid snacking on foods between meals not included in my dietary orders . Meds as my Dr. has ordered . Observe for common side effects of medication including headache, muscle pain, weakness, nausea, vomiting, diarrhea, gas, or stomach pain . The care plan for Diabetes documented, Medication adjustment on 12/13/18, 02/27/19, 03/11/19, 04/09/19, and 04/15/19. No details regarding the medication adjustments were documented. A situation, background, assessment, and recommendation note, dated 5/16/19 at 4:44 a.m., documented the resident's blood sugar had dropped to 48. The note documented the resident was given honey, sugar, and med pass in an attempt to get her blood sugar back up. The note documented the resident's blood sugar was rechecked in 15 minutes and the resident's blood sugar was 55. The note documented the resident's blood sugar was rechecked at 5:45 a.m., and the resident's blood sugar was 84. The note documented the resident was non-responsive, snoring, and was foaming at the mouth. The note documented the physician was not notified. The note documented the resident should receive a snack at night before bedtime to prevent a blood sugar drop. A situation, background, assessment, and recommendation note, dated 5/18/19 at 3:11 a.m., documented the resident's blood sugar was 39. The note documented the resident was given sugar and a quarter teaspoon of jelly, in an attempt to get her blood sugar back up. The note documented the resident's blood sugar was rechecked in 15 minutes and the resident's blood sugar was 55. The note documented staff attempted to administer additional sugar and jelly but the resident did not tolerate it. The note documented the resident was snoring and was foaming at the mouth. The note documented the resident was sent to the emergency room for glucose administration. Emergency Department Physician Notes, from the hospital, dated 05/18/19 at 6:48 a.m., documented, .The patient presents with [DIAGNOSES REDACTED] .The blood sugar was 20 mg/dl .Therapy today: Intravenous [MEDICATION NAME] and emergency medical services. [AGE] year-old female with a history of dementia, she cannot provide any history. All history was obtained from nursing staff as well as nuring home records. She was unresponsive, they checked her sugar and it was 20 .On arrival here the emergency department she had already received 2 A of D50 . The History & Physical from the hospital, dated 05/18/19 at 9:04 a.m., documented, Patient found at NH this am unresponsive with snoring respirations. Her blood glucose was 20, NH attempted oral glucose. EMS gave 250 ml D10 and patient received 2 amps D50. A Communication-Physician Situation note, dated 5/18/19 at 9:39 a.m., documented the nurse practitioner contacted the nurse requesting information on resident finger stick blood sugars and insulin. The note documented the resident was being admitted to the hospital with [REDACTED]. A Patient Discharge to Non-Acute Care Facility Record, from the hospital, dated 05/20/19, documented, All Insulin therapy discontinued See D/C med list .Diagnosis 1. [DIAGNOSES REDACTED] 2. Type 2 DM 3. Insulin Reaction . Clinical Discharge Instructions, from the hospital, dated 05/20/19, documented, .Physician/Provider Discharge Comments: NO INSULIN, last A1C (3/2019) 7. (Hemaglobin A1C of 7 corresponds to an average blood sugar of 152.) No ned (sic) for insulin therapy in this age group, especially when she has persistent [DIAGNOSES REDACTED] . An order note, dated 06/12/19 at 2:07 p.m., documented Basaglar Kwikpen U-100 outer 100 units per milliliter insulin pen inject 25 units subcutaneously one time a day related to diabetes mellitus type II with [MEDICAL CONDITION] and inject 20 units subcutaneously at bedtime with a start date of 06/12/19. The note documented the physician had assessed the resident, reviewed finger stick blood sugars, and labs. The note documented the physician gave a voice order to increase the Basaglar injections to 25 units every a.m. A conversation note, dated 06/28/19 at 1:28 a.m., documented the certified nurse aide was doing rounds and noted the resident was clammy and had a slight tremor in her hands and she asked the nurse to come to the resident's room. The note documented the resident's blood sugar was known to drop in the middle of the night. The note documented the resident's finger stick blood sugar was 54. The note documented the resident was given a pureed snack and med pass. The note documented the resident's finger stick blood sugar would be be re-checked in 30 minutes. There was no documentation to show the physician was notified of the low blood sugar or symptoms of [DIAGNOSES REDACTED]. A conversation note, dated 06/28/19 at 2:05 a.m., documented the resident's blood sugar was rechecked and was 97. A quarterly assessment, dated 07/26/19, documented the resident was moderately impaired in cognitive skills for daily decision making, required extensive assistance with most activities of daily living, and had received insulin seven days out of the seven day look back period. On 08/05/19 at 11:30 a.m., the ADON was asked when the physician should be notified regarding a low blood blood sugar. She stated the physician should be notified if the resident was symptomatic of a low or high blood sugar. She stated the facility did not have specific parameters for notifying the physician with a low or high blood sugar. An EMR, dated 08/06/19, documented: Basaglar Kwikpen U-100 outer 100 units per milliliter insulin pen inject 25 units subcutaneously one time a day related to diabetes mellitus type II with [MEDICAL CONDITION] and inject 20 units subcutaneously at bedtime. On 08/06/19 8:34 a.m., the ADON was asked why the physician was not notified since the resident had symptoms when her blood sugar was low. She stated they should have notified the physician of the resident's low blood sugar level. She was asked what staff could have done to prevent the resident's hospitalization . She stated the physician may have made a change in the resident's medication which may have prevented her from going to the hospital.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident's physician was notified of a resident's change in condition for one (#28) of six resident's whose records were reviewed for notification of a change in condition. The administrator identified 103 residents resided in the faciltiy. The resident experienced an episode of [DIAGNOSES REDACTED] on 05/16/19. The physician was not notified. The resident experienced another episode of [DIAGNOSES REDACTED] that required an emergent transfer and admission to the hospital on [DATE]. Findings: Resident #28 had [DIAGNOSES REDACTED]. An annual assessment, dated 10/26/18, documented the resident was severely cognitively impaired, required extensive assistance with most activities of daily living, and had received insulin seven days out of the seven day look back period. A care plan, initiated on 11/02/18, documented: .I have a dx of Dabetes Mellitus . Goal I will have no complications related to diabetes through the review date . Interventions Adjust meds per physician order [REDACTED].>Check my body for breaks in skin during care and report to nurse . Enc. (encourage) me to avoid snacking on foods between meals not included in my dietary orders . Meds as my Dr. has ordered . Observe for common side effects of medication including headache, muscle pain, weakness, nausea, vomiting, diarrhea, gas, or stomach pain . The care plan for Diabetes documented, Medication adjustment on 12/13/18, 02/27/19, 03/11/19, 04/09/19, and 04/15/19. No details regarding the medication adjustments were documented. A situation, background, assessment, and recommendation note, dated 5/16/19 at 4:44 a.m , documented the resident's blood sugar had dropped to 48. The note documented the resident was given honey, sugar, and med pass in an attempt to get her blood sugar back up. The note documented the resident's blood sugar was rechecked in 15 minutes and the resident's blood sugar was 55. The note documented the resident's blood sugar was rechecked at 5:45 a.m., and the resident's blood sugar was 84. The note documented the resident was non-responsive, snoring, and was foaming at the mouth. The note documented the physician was not notified. The note documented the resident should receive a snack at night before bedtime to prevent a blood sugar drop. A situation, background, assessment, and recommendation note, dated 5/18/19 at 3:11 a.m., documented the resident's blood sugar was 48. The note documented the resident was given sugar and a quarter teaspoon of jelly, in an attempt to get her blood sugar back up. The note documented the resident's blood sugar was rechecked in 15 minutes and the resident's blood sugar was 55. The note documented staff attempted to administer additional sugar and jelly but the resident did not tolerate it. The note documented the resident was snoring and was foaming at the mouth. The note documented the resident was sent to the emergency room for glucose administration. Emergency Department Physician Notes, from the hospital, dated 05/18/19 at 6:48 a.m., documented, .The patient presents with [DIAGNOSES REDACTED] .The blood sugar was 20 mg/dl .Therapy today: Intravenous [MEDICATION NAME] and emergency medical services. [AGE] year-old female with a history of dementia, she cannot provide any history. All history was obtained from nursing staff as well as nuring home records. She was unresponsive, they checked her sugar and it was 20 .On arrival here the emergency department she had already received 2 A of D50 . The History & Physical from the hospital, dated 05/18/19 at 9:04 a.m., documented, Patient found at NH this am unresponsive with snoring respirations. Her blood glucose was 20, NH attempted oral glucose. EMS gave 250 ml D10 and patient received 2 amps D50. A Communication-Physician Situation note, dated 5/18/19 at 9:39 a.m., documented the nurse practitioner contacted the nurse requesting information on resident finger stick blood sugars and insulin. The note documented the resident was being admitted to the hospital with [REDACTED]. An order note, dated 06/12/19 at 2:07 p.m., documented Basaglar Kwikpen U-100 outer 100 units per milliliter insulin pen inject 25 units subcutaneously one time a day related to diabetes mellitus type II with [MEDICAL CONDITION] and inject 20 units subcutaneously at bedtime with a start date of 06/12/19. The note documented the physician had assessed the resident, reviewed finger stick blood sugars, and labs. The note documented the physician gave a voice order to increase the Basaglar injections to 25 units every a.m. A conversation note, dated 06/28/19 at 1:28 a.m., documented a certified nurse aide was doing rounds and noted the resident was clammy and had a slight tremor in her hands and she asked the nurse to come to the resident's room. The note documented the resident's blood sugar was known to drop in the middle of the night. The note documented the resident's finger stick blood sugar was 54. The note documented the resident was given a pureed snack and med pass. The note documented the resident's finger stick blood sugar would be be re-checked in 30 minutes. There was no documentation to show the physician was notified of the low blood sugar and symptoms of [DIAGNOSES REDACTED]. A conversation note, dated 06/28/19 at 2:05 a.m., documented the resident's blood sugar was rechecked and was 97. A quarterly assessment, dated 07/26/19, documented the resident was moderately impaired in cognitive skills for daily decision making, and had received insulin seven days out of the seven day look back period. On 08/05/19 at 11:30 a.m., the ADON was asked when the physician should be notified regarding a low blood blood sugar. She stated the physician should be notified if the resident was symptomatic. She stated the facility did not have specific parameters for notifying the physician with a low or high blood sugar. On 08/06/19 8:34 a.m., the ADON was asked why the physician was not notified since the resident had symptoms when her blood sugar was low. She stated they should have notified the physician of the resident's low blood sugar level. She was asked what staff could have done to prevent the resident's hospitalization . She stated the physician may have made a change in the resident's medication which may have prevented her from going to the hospital.

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene and ensure appropriate treatment was provided for a resident with diabetes for one (#4) of five sampled residents who were reviewed for diabetes care and treatment. Five days after admission, the resident's daily finger stick blood sugar testing and administration of sliding scale insulin was discontinued without any subsequent monitoring of the residents blood glucose levels. The resident was admitted to the hospital with [REDACTED]. The facility identified 16 residents with a [DIAGNOSES REDACTED]. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An EMR, dated 02/02/18, documented, .Humulog Solution Inject as per sliding scale: if 201-250=2 units, 251-300=4 units, 301-350=6 units, 351-400=8 units; greater than 400, give 10 units and call physician, subcutaneously four times a day related to diabetes mellitus due to underlying condition with diabetic [MEDICAL CONDITION] (sic) A treatment administration record, dated (MONTH) (YEAR), documented the resident had finger stick blood sugar testing completed with sliding scale insulin administered as ordered beginning on 02/03/18 and ending on 02/07/18. The finger stick blood sugar results ranged from 119 mg/dl to 351 mg/dl. The resident received sliding scale insulin seven times out of 13 opportunities for FSBS results greater than 200. Nutrition Risk Assessments, dated (MONTH) (YEAR) through (MONTH) (YEAR), were reviewed and contained no documentation or recommendations related to the resident's [DIAGNOSES REDACTED]. A physician's progress note, dated 02/07/18, documented, .Problem list: Type II Diabetes .Serum glucose reviewed diabetes inadequate control .Serum glucose levels and blood pressure orders reviewed and signed. A communication-physician progress notes [REDACTED].Resident new admit .D/C Humulog insulin per sliding scale . Pharmacy consultation reports, dated (MONTH) (YEAR) through (MONTH) 2019, were reviewed and contained no documentation or recommendations related to the resident's [DIAGNOSES REDACTED]. A physician's progress note, dated (MONTH) 4, (YEAR), documented, .Type 2 diabetes presents with serum glucose levels control have discussed target fasting glucose levels an A1c with staff .We'll still need to monitor for elevated serum glucose levels. A1c will be helpful in determining patient's past level of control . A significant change assessment, dated 05/14/18, documented the resident was cognitively intact and required extensive assistance with most activities of daily living. The assessment documented the resident had received no insulin injections during the seven day look back period. A care plan, dted 05/23/18, documented: Focus I have a dx of Diabetes Mellitus . Goal I will have no complications related to diabetes through the review date . Interventions/Tasks Check my body for breaks in skin during care and report to nurse . Enc. me to avoid snacking on foods between meals not included in my dietary orders . Labs as my Dr. has ordered . Physician's progress notes, dated 06/06/18 and 07/11/18, documented the only reference to the resident's [DIAGNOSES REDACTED]. Medical records, dated (MONTH) (YEAR) through (MONTH) 2019, contained no documentation related to the resident's [DIAGNOSES REDACTED]. Physician's progress notes; dated 08/15/18, 09/19/18, 10/24/18, 11/28/18, 12/05/18, and 01/16/19; contained no documentation related to the resident's [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/07/19, documented the resident was cognitively intact and required extensive assistance with activities of daily living. The assessment documented the resident had received no insulin injections during the seven day look back period. A physician's progress note, dated 02/20/19, contained no documentation related to the resident's [DIAGNOSES REDACTED]. Nurses' notes, dated 03/06/19, documented a family member had taken the resident out to see an outside physician and some laboratory tests had been completed including a urinalysis. Nurses' notes, dated 03/07/19, documented the family member reported the urinalysis showed the resident had a urinary tract infection and antibiotics had been called in for the resident. The family member was informed they could not start the antibiotics without a culture and sensitivity report. Nurses' notes, dated 03/11/19, documented the outside physician's office was called regarding the culture and sensitivity report. The notes documented the resident's attending physician would need to reorder the laboratory tests. A physician's telephone order, dated 03/11/19, documented to obtain a TSH, BNP, CMP, HgA1c one time only. The lab results were reviewed and documented the resident's glucose level was 341 mg/dl. The reference range was documented as 70 -105 mg/dl. A laboratory report, dated 03/12/19, documented the resident's blood glucose level was 364 mg/dl and the HgA1c was 11.3. The reference range was documented as 4.2-5.8. The report documented the estimated average glucose level was 278 mg/dl. The clinical records documented the resident had received no medications for her Diabetes other than the sliding scale insulin that was provided from 02/03/18 -02/07/18. A hospital Emergency Department note, dated 03/12/19, documented the resident's glucose level was 445 mg/dl upon admit to the hospital. The reference range was 70 - 105 mg/dl. The History and Physical from the hospital, dated 03/12/19, documented, Assessment/Plan .[MEDICAL CONDITION] Diabetes mellitus type 2 .-she has not been on insulin for the past year .Uncontrolled DM type with severe [MEDICAL CONDITION] . A hospital Discharge Summary, dated 03/18/19, documented, Discharge [DIAGNOSES REDACTED].Chronic neuropathic pain, Uncontrolled type 2 diabetes mellitus with [MEDICAL CONDITION] .Metazolone 2.5 mg daily and [MEDICATION NAME] 40 mg PO BID were held during this hospitalization due to significant AKI related to dehydration from untreated [MEDICAL CONDITION] and diuretics . On 03/25/19 at 10:50 a.m., LPN #1 was asked if she was aware the resident had diabetes. She stated yes. She was asked what kind of treatment the resident was receiving. She stated she was not on insulin but she thought the resident might be receiving [MEDICATION NAME]. She stated she was not sure what medications the resident was receiving related to diabetes. On 03/25/19 at 11:11 a.m., the ADON was asked about the resident's treatment for [REDACTED]. She was asked if she knew why the insulin had been discontinued. She stated no. She was asked why staff had not followed up regarding the resident's diabetes. She stated because the physician had discontinued the resident's insulin. She stated they probably should have followed up. She stated by doing finger stick blood sugars and obtaining a hemoglobin A1c. The ADON was asked how she ensured blood sugars were controlled for a resident who had Diabetes. She stated by doing finger stick blood sugars and obtaining a hemoglobin A1c. The ADON was asked why the resident had been sent to the hospital on [DATE]. She stated the resident's daughter came in to see the resident and felt like she was not acting herself. The ADON stated they had not noticed a change in the resident's condition. She stated the resident's daughter called an ambulance on her own to pick up the resident and take her to the hospital.

Based on observations, interviews, and record reviews, it was determined the facility failed to provide supervision to prevent resident to resident altercations for one (#107) of 4 sampled residents reviewed with aggressive behaviors. Resident #107 was admitted on [DATE] with a history of aggression. After entering the facility it was documented he had initiated four known incidents of resident to resident aggression. It was documented he had been aggressive towards staff. It was documented he wandered into other residents' rooms. On 04/18/18 at 8:57 a.m., he was observed punching his roommate in the face multiple times. He was initially removed from the room and redirected to an activity; however, throughout the morning he was observed ambulating independently and without supervision. Additionally, after the altercation, staff members were observed to again leave him in his room with his roommate alone and without supervision. Resident #107 hit, choked, punched, slapped and urinated on other residents on five different occaisions. The Resident Census and Conditions of Residents form, dated 04/16/18, identified 107 residents resided in the facility. Findings: A facility policy titled, Abuse Prohibition Management Program Resident-to-Resident Incidents, documented: .Attention to Early Warning Signs .If a resident begins to exhibit inappropriate behavior, the facility must assess the resident and promptly intervene, taking appropriate action to protect other residents even if no allegation of abuse is made .Appropriate actions include steps such as additional supervision for aggressive residents and appropriate medical/psychiatric evaluation and treatment. Inappropriate behavior may first be directed towards staff or may be minor in nature. It is important that facilities assess and intervene at this point, rather than after inappropriate behavior is directed toward other residents or the inappropriate behavior escalates. Facility Responsibility .When any resident's behavior constitutes a threat to the health and safety of other residents, the facility must report the behavior and must protect other residents from that threat. Minimum evidence of protection must include both assessment and prompt intervention. The facility must reassess the aggressor's behavior and adjust the plan of care accordingly. The facility must take specific steps to control the aggressor's behavior and to protect other residents. The facility plan of action may include steps such as: *specific psychiatric or medical therapy for the aggressor resident; *additional supervision of residents; *adjustment to facility practices to minimize the risk of occurrences *activities and other interventions that redirect the energies of the aggressor resident; and *care plan changes to minimize the risk of recurrent incidents . A facility policy titled, Abuse Prohibition Management Program Protection of Residents During Abuse Investigations, documented: .During abuse investigations, residents will be protected from harm by the following measures .If the alleged abuse involves another resident .the accused resident will not be permitted to make visits to other resident rooms unattended . A facility policy titled, Abuse Prohibition Management Program Investigating Allegations of Resident to Resident Abuse, documented: .Should a resident be observed/accused of abusing another resident, implement the following protocol: a. Remove the aggressor from the situation . b. Temporarily separate the resident from other residents as a therapeutic intervention to help reduce the agitation until the interdisciplinary care planning team can develop a plan of care to meet the needs of the resident . f. Develop a care plan that includes interventions to prevent the recurrence of such incident . g. Inform all staff involved in the care of the resident of the care plan and to promptly report behavioral changes to the charge nurse; h. Document in the resident's clinical record all interventions and their effectiveness . A facility policy titled, Investigating Allegations of Physical Abuse, documented: .physical abuse is defined as hitting, slapping, pinching, kicking . Resident #107 had [DIAGNOSES REDACTED]. A psychiatric admission note, dated 03/10/18, documented, .Patient brought to (Named facility) by wife who repots (sic. reports) patient has become increasingly aggressive in the recent past to the point of physically assaulting wife who acts a caretaker .Psychiatric Examination .Danger to Others Inventory: Impulsive aggression towards others . A baseline care plan, dated 03/23/18, documented the resident entered the facility from a psychiatric hospital and had a history of [REDACTED]. A behavior progress note, dated 03/24/18 at 8:37 p.m., documented the resident urinated on another resident's leg. It was documented the nurse removed him from the situation. The intervention put in place to prevent recurrence was the resident would be provided with assistance during bowel and bladder training. It was documented the physician would be notified in rounds and the family would be notified if the behavior persisted. A behavior progress note, dated 03/26/18 at 12:17 p.m., documented the resident hit and choked another resident while in the dining room. It was also documented the resident was aggressive to the staff as he was brought out of the dining room. It was documented non-pharmacological approaches used to reduce/resolve the behavior were redirection and bringing the resident out of the dining room. These interventions were documented as effective, and it was documented the behavior was resolved. The intervention put in place to prevent a recurrence was continued redirection. An incident report, dated 03/28/18 at 6:55 p.m., documented the resident was found in another resident's room in a fetal position and appeared sleeping. While the resident was referred to therapy, there was no documentation of increased supervision related to wandering into another resident's room. A behavior progress note, dated 04/01/18 at 11:44 p.m., documented the resident punched another resident in the neck in the dining room. It was documented non-pharmacological approaches used to reduce/resolve the behavior were redirection and the separation of the residents. The results of the non-pharmacological interventions were documented as, Problem solved. In the note there was no documentation of interventions in place to prevent recurrence. There was no documentation of increased supervision related to the resident's aggressive behavior towards another resident. An incident, dated 04/02/18 at 9:48 a.m., documented the resident was pushing a female resident in her wheelchair. When she asked him to stop pushing her, he slapped her in the face causing her glasses to come off of her face. Steps taken to prevent recurrence were documented as redirecting, monitoring behaviors, and keeping residents separate. A progress note corresponding to this incident report, dated 04/02/18 10:14 a.m., documented non-pharmacological approaches used to reduce/resolve the behavior were continued redirection of resident and separation of the residents involved. It was documented the results of the non-pharmacological interventions were effective. It was documented the behavior resolved. It was documented interventions in place to prevent a recurrence were to continue to monitor behaviors and redirect the resident. There was no documentation of increased supervision related to the resident's aggressive behavior towards another resident. A behavior progress note, dated 04/02/18 at 11:31 p.m., documented the resident was exhibiting the behavior of wandering. It was documented redirection worsened the behavior. It was documented the intervention put in place to prevent a recurrence was staff supervision. It was not documented which staff specifically were to supervise the resident. It was not documented how long the supervision should last. A progress note, dated 04/03/18 at 3:52 a.m., documented the resident went into another resident's room and flooded their restroom. There was no documentation the resident was under staff supervision at that time. A behavior progress note, dated 04/03/18 at 2:15 p.m., documented the resident was wandering in and out of other residents' rooms. It was documented that non-pharmacological approaches used to reduce/resolve the behavior were redirection but that redirection was ineffective. It was documented interventions in place to prevent a recurrence were to continue redirection. There was no documentation of staff supervision to prevent aggressive or wandering behaviors. A progress note, dated 04/03/18 at 7:49 p.m., documented the physician was informed the resident was found lying in another resident's floor. The note documented the resident was apparently pilfering through the brief drawer for the drawer was open and his feet was under the drawer. Interventions implemented were to administer [MEDICATION NAME] 14 mg (milligrams) twice a day routinely and every 8 hours as needed. Additionally, [MEDICATION NAME] 25 mg was to be administered at bedtime. There was no documentation the resident was under staff supervision at that time. A behavior progress note, dated 04/04/18 at 12:59 p.m., documented the resident began to get aggressive with a nurse when he was told not to touch the computer. It was documented non-pharmacological approaches used to prevent a recurrence was redirection. There was no documentation of staff supervision related to the resident's aggressive behavior. An admission assessment, dated 04/04/18, documented the resident was severely impaired in skills for daily decision making and experienced delusions. It documented the resident had behaviors that put others at risk for physical injury, intruded on the privacy or activities of others, significantly disrupted the care or living environment and wandered daily. It documented he required supervision for walking in his room, walking in the corridor and locomotion between locations on the unit, but he did not require any physical help from staff. A care plan, dated 04/06/18, documented, .Focus .I demonstrate physical behaviors towards others . Goal .I will not harm self or others . Interventions .Assess and anticipate my needs: food, thirst. toileting needs, comfort level, body positioning, pain .enc (sic. encourage) my family and friends to visit frequently .Evaluate for side effects of my medications .Offer me limited choices as possible about care and activities, so that I do not become overwhelmed .Redirect me as needed .Redirect me away from residents that I am attempting to push in wheelchair . A care plan, dated 04/06/18, documented, .Focus .I am experiencing s/sx (signs and symptoms) of a mood disorder and a psychosocial well-being problem . Goal .I will have improved mood state .no outbursts, socializing with peers and no disruptive behaviors . Interventions .use kind quiet words during outbursts. try to redirect if possible . The care plan did not include an intervention of staff supervision to prevent recurrences of aggressive behaviors. A behavior progress note, dated 04/17/18 at 4:04 a.m., documented the resident was up most of the shift and was trying to go into other residents' rooms. It was documented he would swing at staff when redirected out of a resident's room while they were asleep. It was documented that redirection worsened the behavior. It was documented non-pharmacological approaches of a drink and snack was not effective and the behavior did not resolve. It was documented interventions in place to prevent a recurrence was a prn (as needed) anxiety medication. On 04/17/18 at 9:11 a.m., the resident was observed to enter a female resident's room (resident #51). There were no staff members supervising him. Resident #51 yelled, Get out of here. You're in the wrong room. The resident did not leave the room. No staff were supervising, and no staff responded. Again the female resident yelled, Get out of here. You're in the wrong room. The resident did not leave the room immediately as she requested and instead stood in her room. At 9:14 a.m. he left resident #51's room. A behavior progress note, dated 04/17/18 at 11:43 p.m., documented the resident was hitting staff. It was documented that redirection worsened the behavior. It was documented non-pharmacological approaches used to reduce/resolve the behavior included redirection and removing the resident from the area and these interventions were effective. It was documented interventions put in place to prevent a recurrence included assessing and anticipating needs, offering limited choices, and redirecting as needed. There was no documentation of increased staff supervision related to the resident's aggressive behavior. On 04/18/18 at 8:24 a.m., the resident was observed entering a female resident's (#51) room. CNA #3 led the resident out of this room to his own room and assisted him to sit in his roommate's recliner. At 8:47 a.m., the resident walked into the hallway, mumbled some words, went back into the room and sat down in the recliner on his roommates' side of the room. The roommate, resident #64, entered the room, rolled his wheelchair to the side of his bed and began pushing up on the armrests of his wheelchair in an attempt to gain momentum to transfer himself. At 8:50 a.m., resident #64 transferred himself to his bed and was sitting on the edge of his bed toward the feet side of the bed. The resident remained seated in the recliner directly beside the head of resident #64's bed. The residents were observed looking at each other, but nothing was said. At 8:54 a.m., the roommate, resident #64, swung his legs onto the bed and was positioned in the middle of the bed. He was tentatively watching the resident who remained seated in the recliner right beside the head of the bed. At 8:56 a.m., the roommate, resident #64, scooted himself up in bed and laid his head on his pillow. The resident remained seated in the recliner only a few inches away from resident #64. At 8:57 a.m., the resident stood up and punched resident #64 in the face several times. Resident #64 rose up off his pillow in an attempt to defend himself, but he could not stop the resident from hitting him. CMA #4 came into the room and called out that the resident was hitting resident #64 in the face. LPN #1 removed the resident from the room. Resident #64 was observed to have tears in his eyes and looked afraid. LPN #3 assessed resident #64. LPN #3 was asked if resident #64 had injuries. She stated he had bleeding gums, and his nose and mouth were red. LPN #1 returned to the room and was asked if the resident (#107) was sitting in his roommate's chair and on his roommate's side of the room when the altercation occurred. She answered the residents are known to sit in each others chairs. She stated that she has come into the room and found the resident sitting on the end of resident #64 's bed, but she stated there had never been any altercations. She stated the resident (#107) had been moved to an activity. There was no observation the resident had been placed on increased staff supervision following the altercation with resident #64. An incident report, dated 04/18/18 at 9:05 a.m., documented the resident was found in his room hitting his roommate in the face. His roommate was documented to have injury, redness to L (left) lip and bleeding from gums. It was documented steps taken to prevent recurrence included separation of residents and redirection of the resident when aggression starts. There was no documentation of increased staff supervision. At 9:55 a.m., resident #64 was observed in his bed. He was asked if he was hurt. He pointed to his left check. He did not say anything. At 10:20 a.m., resident #107 was observed ambulating independently in the lobby area and the hall. There were no staff members observed supervising the resident. At 10:33 a.m., he was placed at a table with three other residents. There were 27 residents in the dining room with one staff member and one family member. At 11:45 a.m., resident #79 was asked if she was afraid of anyone. She said, No, but there are some (residents) that will come in your room and hit you. She did not provide any names. At 11:50 a.m., the speech therapist was observed working with the resident. She stated she only worked with him for eating but had observed him intimidatingly scowling at other residents. At 12:15 p.m., LPN #3 was asked what steps were taken if a resident was aggressive to other residents. She identified redirection and reorientation as interventions for aggressive residents. Supervision was not mentioned as an intervention. At 12:17 p.m., resident #51 was asked if there was anyone who came into her room and made her afraid. She stated older men came into her room and tried to hit her. She stated she did not know their names but would just tell them to get out. She stated it was so frustrating to be woken up by a man trying to hit her. At 12:20 p.m., the resident was removed from the dining room and placed in the activity room. The charge nurse identified a hospice aide and a family member in the room, but there were no facility staff in the room to supervise the resident. At 12:20 p.m., CNA #3 was asked what steps were taken if a resident was aggressive to other residents. She stated residents needed to be guided in the right direction. Staff supervision was not mentioned as an intervention. At 12:20 p.m., the DON was asked what steps were taken if a resident was aggressive to another resident. She stated the residents were separated immediately and the aggressor was kept busy so they forget what they were doing. She further stated if the altercation resulted in an injury 1:1 staff supervision was implemented until the resident could be transferred to a psychiatric hospital. She stated if empty rooms were available the resident might be moved. She was asked if there was a resident who was aggressive with staff. She stated there was no one specific. It just happens. At 12:22 p.m., CNA #4 was asked if any residents were aggressive. She stated she had seen resident #107 attack a lot of people. She was asked what she did when that happened. She stated she redirected the resident and got the nurse. Staff supervision was not mentioned as an intervention. At 12:24 p.m., CNA #5 was asked what steps were taken if a resident was aggressive to other residents. She stated residents should be redirected. Staff supervision was not mentioned as an intervention. At 12:26 p.m., CNA #6 was asked what steps were taken if a resident was aggressive to other residents. She stated residents should be removed from the situation. Staff supervision was not mentioned as an intervention. At 12:28 p.m., CNA #7 was asked what steps were taken if a resident was aggressive to other residents. She stated residents should be redirected and help obtained. Staff supervision was not mentioned as an intervention. At 12:36 p.m., the resident (#107) was observed in a chair in the activity room. Staff were in and out of the room bringing in residents from the dining room. There was no staff member observed to supervise the resident. At 12:50 p.m., the resident was observed sitting in the activity room surrounded by other residents. There were no staff nearby. The nurse's station was about thirty feet away. At 1:02 p.m., the resident began walking unsupervised. There were no staff observed in sight. At 1:09 p.m., he tried to exit the building with another resident. There was no staff observed in sight. At 1:15 p.m., he was still standing by the exit door, but then he took two steps into a resident's room by the exit door. There was no staff observed in sight. At 1:27 p.m., a staff member was observed escorting the resident to his room, placing him in his recliner, and leaving him alone with his roommate. The roommate was in his wheelchair facing the bed. There were no staff in the hall, and there was no other staff supervision of the resident. At 1:35 p.m., his roommate had transferred himself into the bed. Staff entered the room to help the roommate lie down, and once again both residents were left unsupervised in the room. At 1:40 p.m., both residents remained alone in the room. At 1:45 p.m., resident #107 left the room but quickly returned with an aide who helped him sit on the edge of his bed and then left the room to get covers. The aide closed the door halfway, and the residents were left unsupervised. At 1:46 p.m., two aides returned, covered both residents, and then left the room leaving the residents unsupervised. A related progress note, dated 04/18/18 at 2:15 p.m., documented the resident was found in his room hitting his roommate in the face. It was documented prior to the incident he was sitting in the recliner next to the roommates' bed. It was documented non-pharmacological approaches used to reduce/resolve the behavior included removing the resident from the room and taking him to the TV room. The result of this intervention was considered effective. It was documented the behavior was resolved. It was documented interventions in place to prevent a recurrence included, monitor the resident while in room and monitor resident behavior around other resident. There was no documentation of staff monitoring the resident's aggressive behavior. On 04/18/18 at 5:40 p.m. the resident was observed in the dining room. He was not on 1:1 staff supervision. He was observed taking a female resident's hamburger and eating it. He was escorted out of the dining room into the hallway. He made his way to the activity room where he wandered unsupervised. He once again picked up food from another resident's plate. The charge nurse asked him to sit in a chair, but he did not. He paced the hallway and activity room followed by the DON. The DON was asked if a staff member was assigned to supervise him 1:1. She stated CNA #8 was assigned. CNA #8 was observed assisting another resident in the dining room. She was asked if she was assigned to watch resident #107, 1:1. She stated she was only supposed to watch him until 3:00 p.m. She was asked who was supposed to watch him after that. She said she thought they were only supposed to watch him 1:1 until 3:00 p.m. LPN #5 who was the charge nurse was asked what staff member was assigned to one on one observation with the observed resident. She said, We don't have any residents on one on one observation. At 5:41 p.m., administrator #1 was notified LPN #5/charge nurse was unaware the resident was supposed to be on one on one staff supervision. She was notified no staff member had been assigned to provide one on one supervision after 3:00 p.m. The resident was also observed ambulating without staff supervision. She stated aggressive behaviors and resident to resident altercations happen on the unit. She stated we don't want to chemically restrain residents so we provide redirection.

Based on observations, interviews, and record reviews, it was determined the facility failed to prevent reoccurring resident to resident abuse by one (#107) of four sampled residents reviewed with aggressive behaviors towards other residents/staff. Resident #107 was admitted on [DATE] with a history of aggression. After entering the facility it was documented he had initiated four known incidents of resident to resident aggression. It was documented he had been aggressive towards staff. It was documented he wandered into other residents' rooms. On 04/18/18 at 8:57 a.m., he was observed punching his roommate in the face multiple times. He was initially removed from the room and redirected to an activity; however, throughout the morning he was observed ambulating independently and without supervision. Additionally, after the altercation, staff members were observed to again leave him in his room with his roommate alone and without supervision. Resident #107 hit, choked, punched, slapped and urinated on other residents on five different occaisions. The Resident Census and Conditions of Residents form, dated 04/16/18, documented 107 residents resided in the facility. Findings: A facility policy titled, Abuse Prohibition Management Program Resident-to-Resident Incidents, documented: .Attention to Early Warning Signs .If a resident begins to exhibit inappropriate behavior, the facility must assess the resident and promptly intervene, taking appropriate action to protect other residents even if no allegation of abuse is made .Appropriate actions include steps such as additional supervision for aggressive residents and appropriate medical/psychiatric evaluation and treatment. Inappropriate behavior may first be directed towards staff or may be minor in nature. It is important that facilities assess and intervene at this point, rather than after inappropriate behavior is directed toward other residents or the inappropriate behavior escalates. Facility Responsibility .When any resident's behavior constitutes a threat to the health and safety of other residents, the facility must report the behavior and must protect other residents from that threat. Minimum evidence of protection must include both assessment and prompt intervention. The facility must reassess the aggressor's behavior and adjust the plan of care accordingly. The facility must take specific steps to control the aggressor's behavior and to protect other residents. The facility plan of action may include steps such as: *specific psychiatric or medical therapy for the aggressor resident; *additional supervision of residents; *adjustment to facility practices to minimize the risk of occurrences *activities and other interventions that redirect the energies of the aggressor resident; and *care plan changes to minimize the risk of recurrent incidents . A facility policy titled, Abuse Prohibition Management Program Protection of Residents During Abuse Investigations, documented: .During abuse investigations, residents will be protected from harm by the following measures .If the alleged abuse involves another resident .the accused resident will not be permitted to make visits to other resident rooms unattended . A facility policy titled, Abuse Prohibition Management Program Investigating Allegations of Resident to Resident Abuse, documented: .Should a resident be observed/accused of abusing another resident, implement the following protocol: a. Remove the aggressor from the situation . b. Temporarily separate the resident from other residents as a therapeutic intervention to help reduce the agitation until the interdisciplinary care planning team can develop a plan of care to meet the needs of the resident . f. Develop a care plan that includes interventions to prevent the recurrence of such incident . g. Inform all staff involved in the care of the resident of the care plan and to promptly report behavioral changes to the charge nurse; h. Document in the resident's clinical record all interventions and their effectiveness . A facility policy titled, Investigating Allegations of Physical Abuse, documented: .physical abuse is defined as hitting, slapping, pinching, kicking . Resident #107 had [DIAGNOSES REDACTED]. A psychiatric admission note, dated 03/10/18, documented, .Patient brought to (Named facility) by wife who repots (sic. reports) patient has become increasingly aggressive in the recent past to the point of physically assaulting wife who acts a caretaker .Psychiatric Examination .Danger to Others Inventory: Impulsive aggression towards others . A baseline care plan, dated 03/23/18, documented the resident entered the facility from a psychiatric hospital and had a history of [REDACTED]. A behavior progress note, dated 03/24/18 at 8:37 p.m., documented the resident urinated on another resident's leg. It was documented the nurse removed him from the situation. The intervention put in place to prevent recurrence was the resident would be provided with assistance during bowel and bladder training. It was documented the physician would be notified in rounds and the family would be notified if the behavior persisted. A behavior progress note, dated 03/26/18 at 12:17 p.m., documented the resident hit and choked another resident while in the dining room. It was also documented the resident was aggressive to the staff as he was brought out of the dining room. It was documented non-pharmacological approaches used to reduce/resolve the behavior were redirection and bringing the resident out of the dining room. These interventions were documented as effective, and it was documented the behavior was resolved. The intervention put in place to prevent a recurrence was continued redirection. An incident report, dated 03/28/18 at 6:55 p.m., documented the resident was found in another resident's room in a fetal position and appeared sleeping. While the resident was referred to therapy, there was no documentation of increased supervision related to wandering into another resident's room. A behavior progress note, dated 04/01/18 at 11:44 p.m., documented the resident punched another resident in the neck in the dining room. It was documented non-pharmacological approaches used to reduce/resolve the behavior were redirection and the separation of the residents. The results of the non-pharmacological interventions were documented as, Problem solved. In the note there was no documentation of interventions in place to prevent recurrence. There was no documentation of increased supervision related to the resident's aggressive behavior towards another resident. An incident, dated 04/02/18 at 9:48 a.m., documented the resident was pushing a female resident in her wheelchair. When she asked him to stop pushing her, he slapped her in the face causing her glasses to come off of her face. Steps taken to prevent recurrence were documented as redirecting, monitoring behaviors, and keeping residents separate. A progress note corresponding to this incident report, dated 04/02/18 10:14 a.m., documented non-pharmacological approaches used to reduce/resolve the behavior were continued redirection of resident and separation of the residents involved. It was documented the results of the non-pharmacological interventions were effective. It was documented the behavior resolved. It was documented interventions in place to prevent a recurrence were to continue to monitor behaviors and redirect the resident. There was no documentation of increased supervision related to the resident's aggressive behavior towards another resident. A behavior progress note, dated 04/02/18 at 11:31 p.m., documented the resident was exhibiting the behavior of wandering. It was documented redirection worsened the behavior. It was documented the intervention put in place to prevent a recurrence was staff supervision. It was not documented which staff specifically were to supervise the resident. It was not documented how long the supervision should last. A progress note, dated 04/03/18 at 3:52 a.m., documented the resident went into another resident's room and flooded their restroom. There was no documentation the resident was under staff supervision at that time. A behavior progress note, dated 04/03/18 at 2:15 p.m., documented the resident was wandering in and out of other residents' rooms. It was documented that non-pharmacological approaches used to reduce/resolve the behavior were redirection but that redirection was ineffective. It was documented interventions in place to prevent a recurrence were to continue redirection. There was no documentation of staff supervision to prevent aggressive or wandering behaviors. A progress note, dated 04/03/18 at 7:49 p.m., documented the physician was informed the resident was found lying in another resident's floor. The note documented the resident was apparently pilfering through the brief drawer for the drawer was open and his feet was under the drawer. Interventions implemented were to administer [MEDICATION NAME] 14 mg (milligrams) twice a day routinely and every 8 hours as needed. Additionally, [MEDICATION NAME] 25 mg was to be administered at bedtime. There was no documentation the resident was under staff supervision at that time. A behavior progress note, dated 04/04/18 at 12:59 p.m., documented the resident began to get aggressive with a nurse when he was told not to touch the computer. It was documented non-pharmacological approaches used to prevent a recurrence was redirection. There was no documentation of staff supervision related to the resident's aggressive behavior. An admission assessment, dated 04/04/18, documented the resident was severely impaired in skills for daily decision making and experienced delusions. It documented the resident had behaviors that put others at risk for physical injury, intruded on the privacy or activities of others, significantly disrupted the care or living environment and wandered daily. It documented he required supervision for walking in his room, walking in the corridor and locomotion between locations on the unit, but he did not require any physical help from staff. A care plan, dated 04/06/18, documented, .Focus .I demonstrate physical behaviors towards others . Goal .I will not harm self or others . Interventions .Assess and anticipate my needs: food, thirst. toileting needs, comfort level, body positioning, pain .enc (sic. encourage) my family and friends to visit frequently .Evaluate for side effects of my medications .Offer me limited choices as possible about care and activities, so that I do not become overwhelmed .Redirect me as needed .Redirect me away from residents that I am attempting to push in wheelchair . A care plan, dated 04/06/18, documented, .Focus .I am experiencing s/sx (signs and symptoms) of a mood disorder and a psychosocial well-being problem . Goal .I will have improved mood state .no outbursts, socializing with peers and no disruptive behaviors . Interventions .use kind quiet words during outbursts. try to redirect if possible . The care plan did not include an intervention of staff supervision to prevent recurrences of aggressive behaviors. A behavior progress note, dated 04/17/18 at 4:04 a.m., documented the resident was up most of the shift and was trying to go into other residents' rooms. It was documented he would swing at staff when redirected out of a resident's room while they were asleep. It was documented that redirection worsened the behavior. It was documented non-pharmacological approaches of a drink and snack was not effective and the behavior did not resolve. It was documented interventions in place to prevent a recurrence was a prn (as needed) anxiety medication. On 04/17/18 at 9:11 a.m., the resident was observed to enter a female resident's room (resident #51). There were no staff members supervising him. Resident #51 yelled, Get out of here. You're in the wrong room. The resident did not leave the room. No staff were supervising, and no staff responded. Again the female resident yelled, Get out of here. You're in the wrong room. The resident did not leave the room immediately as she requested and instead stood in her room. At 9:14 a.m. he left resident #51's room. A behavior progress note, dated 04/17/18 at 11:43 p.m., documented the resident was hitting staff. It was documented that redirection worsened the behavior. It was documented non-pharmacological approaches used to reduce/resolve the behavior included redirection and removing the resident from the area and these interventions were effective. It was documented interventions put in place to prevent a recurrence included assessing and anticipating needs, offering limited choices, and redirecting as needed. There was no documentation of increased staff supervision related to the resident's aggressive behavior. On 04/18/18 at 8:24 a.m., the resident was observed entering a female resident's (#51) room. CNA #3 led the resident out of this room to his own room and assisted him to sit in his roommate's recliner. At 8:47 a.m., the resident walked into the hallway, mumbled some words, went back into the room and sat down in the recliner on his roommates' side of the room. The roommate, resident #64, entered the room, rolled his wheelchair to the side of his bed and began pushing up on the armrests of his wheelchair in an attempt to gain momentum to transfer himself. At 8:50 a.m., resident #64 transferred himself to his bed and was sitting on the edge of his bed toward the feet side of the bed. The resident remained seated in the recliner directly beside the head of resident #64's bed. The residents were observed looking at each other, but nothing was said. At 8:54 a.m., the roommate, resident #64, swung his legs onto the bed and was positioned in the middle of the bed. He was tentatively watching the resident who remained seated in the recliner right beside the head of the bed. At 8:56 a.m., the roommate, resident #64, scooted himself up in bed and laid his head on his pillow. The resident remained seated in the recliner only a few inches away from resident #64. At 8:57 a.m., the resident stood up and punched resident #64 in the face several times. Resident #64 rose up off his pillow in an attempt to defend himself, but he could not stop the resident from hitting him. CMA #4 came into the room and called out that the resident was hitting resident #64 in the face. LPN #1 removed the resident from the room. Resident #64 was observed to have tears in his eyes and looked afraid. LPN #3 assessed resident #64. LPN #3 was asked if resident #64 had injuries. She stated he had bleeding gums, and his nose and mouth were red. LPN #1 returned to the room and was asked if the resident (#107) was sitting in his roommate's chair and on his roommate's side of the room when the altercation occurred. She answered the residents are known to sit in each others chairs. She stated that she has come into the room and found the resident sitting on the end of resident #64 's bed, but she stated there had never been any altercations. She stated the resident (#107) had been moved to an activity. There was no observation the resident had been placed on increased staff supervision following the altercation with resident #64. An incident report, dated 04/18/18 at 9:05 a.m., documented the resident was found in his room hitting his roommate in the face. His roommate was documented to have injury, redness to L (left) lip and bleeding from gums. It was documented steps taken to prevent recurrence included separation of residents and redirection of the resident when aggression starts. There was no documentation of increased staff supervision. At 9:55 a.m., resident #64 was observed in his bed. He was asked if he was hurt. He pointed to his left check. He did not say anything. At 10:20 a.m., resident #107 was observed ambulating independently in the lobby area and the hall. There were no staff members observed supervising the resident. At 10:33 a.m., he was placed at a table with three other residents. There were 27 residents in the dining room with one staff member and one family member. At 11:45 a.m., resident #79 was asked if she was afraid of anyone. She said, No, but there are some (residents) that will come in your room and hit you. She did not provide any names. At 11:50 a.m., the speech therapist was observed working with the resident. She stated she only worked with him for eating but had observed him intimidatingly scowling at other residents. At 12:15 p.m., LPN #3 was asked what steps were taken if a resident was aggressive to other residents. She identified redirection and reorientation as interventions for aggressive residents. Supervision was not mentioned as an intervention. At 12:17 p.m., resident #51 was asked if there was anyone who came into her room and made her afraid. She stated older men came into her room and tried to hit her. She stated she did not know their names but would just tell them to get out. She stated it was so frustrating to be woken up by a man trying to hit her. At 12:20 p.m., the resident was removed from the dining room and placed in the activity room. The charge nurse identified a hospice aide and a family member in the room, but there were no facility staff in the room to supervise the resident. At 12:20 p.m., CNA #3 was asked what steps were taken if a resident was aggressive to other residents. She stated residents needed to be guided in the right direction. Staff supervision was not mentioned as an intervention. At 12:20 p.m., the DON was asked what steps were taken if a resident was aggressive to another resident. She stated the residents were separated immediately and the aggressor was kept busy so they forget what they were doing. She further stated if the altercation resulted in an injury 1:1 staff supervision was implemented until the resident could be transferred to a psychiatric hospital. She stated if empty rooms were available the resident might be moved. She was asked if there was a resident who was aggressive with staff. She stated there was no one specific. It just happens. At 12:22 p.m., CNA #4 was asked if any residents were aggressive. She stated she had seen resident #107 attack a lot of people. She was asked what she did when that happened. She stated she redirected the resident and got the nurse. Staff supervision was not mentioned as an intervention. At 12:24 p.m., CNA #5 was asked what steps were taken if a resident was aggressive to other residents. She stated residents should be redirected. Staff supervision was not mentioned as an intervention. At 12:26 p.m., CNA #6 was asked what steps were taken if a resident was aggressive to other residents. She stated residents should be removed from the situation. Staff supervision was not mentioned as an intervention. At 12:28 p.m., CNA #7 was asked what steps were taken if a resident was aggressive to other residents. She stated residents should be redirected and help obtained. Staff supervision was not mentioned as an intervention. At 12:36 p.m., the resident (#107) was observed in a chair in the activity room. Staff were in and out of the room bringing in residents from the dining room. There was no staff member observed to supervise the resident. At 12:50 p.m., the resident was observed sitting in the activity room surrounded by other residents. There were no staff nearby. The nurse's station was about thirty feet away. At 1:02 p.m., the resident began walking unsupervised. There were no staff observed in sight. At 1:09 p.m., he tried to exit the building with another resident. There was no staff observed in sight. At 1:15 p.m., he was still standing by the exit door, but then he took two steps into a resident's room by the exit door. There was no staff observed in sight. At 1:27 p.m., a staff member was observed escorting the resident to his room, placing him in his recliner, and leaving him alone with his roommate. The roommate was in his wheelchair facing the bed. There were no staff in the hall, and there was no other staff supervision of the resident. At 1:35 p.m., his roommate had transferred himself into the bed. Staff entered the room to help the roommate lie down, and once again both residents were left unsupervised in the room. At 1:40 p.m., both residents remained alone in the room. At 1:45 p.m., resident #107 left the room but quickly returned with an aide who helped him sit on the edge of his bed and then left the room to get covers. The aide closed the door halfway, and the residents were left unsupervised. At 1:46 p.m., two aides returned, covered both residents, and then left the room leaving the residents unsupervised. A related progress note, dated 04/18/18 at 2:15 p.m., documented the resident was found in his room hitting his roommate in the face. It was documented prior to the incident he was sitting in the recliner next to the roommates' bed. It was documented non-pharmacological approaches used to reduce/resolve the behavior included removing the resident from the room and taking him to the TV room. The result of this intervention was considered effective. It was documented the behavior was resolved. It was documented interventions in place to prevent a recurrence included, monitor the resident while in room and monitor resident behavior around other resident. There was no documentation of staff monitoring the resident's aggressive behavior. On 04/18/18 at 5:40 p.m. the resident was observed in the dining room. He was not on 1:1 staff supervision. He was observed taking a female resident's hamburger and eating it. He was escorted out of the dining room into the hallway. He made his way to the activity room where he wandered unsupervised. He once again picked up food from another resident's plate. The charge nurse asked him to sit in a chair, but he did not. He paced the hallway and activity room followed by the DON. The DON was asked if a staff member was assigned to supervise him 1:1. She stated CNA #8 was assigned. CNA #8 was observed assisting another resident in the dining room. She was asked if she was assigned to watch resident #107, 1:1. She stated she was only supposed to watch him until 3:00 p.m. She was asked who was supposed to watch him after that. She said she thought they were only supposed to watch him 1:1 until 3:00 p.m. LPN #5 who was the charge nurse was asked what staff member was assigned to one on one observation with the observed resident. She said, We don't have any residents on one on one observation. At 5:41 p.m., administrator #1 was notified LPN #5/charge nurse was unaware the resident was supposed to be on one on one staff supervision. She was notified no staff member had been assigned to provide one on one supervision after 3:00 p.m. The resident was also observed ambulating without staff supervision. She stated aggressive behaviors and resident to resident altercations happen on the unit. She stated we don't want to chemically restrain residents so we provide redirection.