Every finding on record at Oak View Home, Inc

Based on observation, staff interview, and review of the facility policies titled Storage Areas and Cleaning and Sanitizing, the facility failed to ensure food items were discarded on or before the discard or expiration date. In addition, the facility failed to maintain sanitary conditions for dishware and utensils. The deficient practices had the potential to place the 80 residents receiving nutrition and hydration from the kitchen at increased risk of foodborne illness. Findings include: Review of the facility policy titled Storage Areas, reviewed 12/27/2024, revealed the Guideline section included, First in first out (FIFO) should be followed.Review of facility policy titled Cleaning and Sanitizing, reviewed 12/27/2024, revealed the Intent section included, It is the intent of this center to clean and sanitize utensils, dishware, pots and pans, workspace, and equipment to minimize the risk of food-borne illnesses.Observations during a tour of the kitchen on 9/16/2025 at 7:42 am, with [NAME] CC, revealed: The dry storage area contained one opened, unlabeled 21-oz. (ounce) taco seasoning with an expiration date of 7/27/2025. The reach-in refrigerator contained three 46-oz. containers of opened thickener, unlabeled and undated.Further observations during the tour revealed that the vegetable preparation sink was rusty and the ventilation above the sink had a buildup of fuzzy material. Continued observation revealed food substance on cups that had been washed and were dry. In an interview on 9/16/2025 at 9:31 am, Dietary Aide (DA) AA stated that her responsibilities included washing dishware and utensils using the high-temperature dishwasher. She stated she occasionally scraped food off of the dishware, but she typically rinsed it off. In an interview on 9/16/2025 at 9:37 am, DA BB stated that her responsibilities consisted of utilizing the high-temperature dishwasher and storing the dry dishware. DA BB acknowledged the presence of food substances on the cups and stated that she did not inspect the dishware. She stated she was aware that this oversight could pose a risk of illness to residents.In an interview on 9/18/2025 at 11:39 am, the Certified Dietary Manager (CDM) stated that both the CDM and all staff members were responsible for checking the labels and expiration dates on every food item, and discarding the item on or before the discard date and expiration date. The CDM confirmed the food substances on the cups and stated that the dietary staff responsible for dishwashing will undergo training.

Based on observations, staff interviews, record review, and review of the facility's policy titled Use of Oxygen Therapy, the facility failed to ensure that one of 13 residents (R) (R3) with oxygen orders was administered oxygen therapy in accordance with the physician's orders. This deficient practice had the potential to place R3 at increased risk of respiratory complications. Findings include:Review of the facility's policy titled Use of Oxygen Therapy, reviewed 12/27/2024, revealed the Guideline section included, Physician's order for oxygen should be obtained and include: Oxygen with liter flow as ordered.Review of the Face Sheet for R3 revealed diagnoses including, but not limited to, chest pain, shortness of breath, chronic bronchitis, and chronic respiratory failure with hypoxia.Review of the Annual Minimum Data Set (MDS) for R3, dated 7/21/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen. Review of the care plan for R3 revealed a care area of respiratory difficulties. Interventions included administering oxygen as ordered. Review of the physician's order for R3 revealed an order dated 1/5/2025 for oxygen via a nasal cannula (NC) at 2 liters per minute (LPM) every 24 hours, every eight hours. Observation on 9/16/2025 at 12:18 pm revealed R3 receiving oxygen via NC via an oxygen concentrator with the flow meter set on 3.5 LPM. Observation on 9/16/2025 at 3:05 pm revealed R3 receiving oxygen via NC via an oxygen concentrator with the flow meter set on 3.5 LPM.Observation on 9/17/2025 at 8:46 am revealed R3 receiving oxygen via NC via an oxygen concentrator with the flow meter set on 3.5 LPM.In an interview on 9/17/2025 at 8:50 am, Licensed Practical Nurse (LPN) CC confirmed that R3's physician orders included an order for oxygen at 2 LPM via a NC. LPN CC verified the flow meter was set to 3.5 LPM on R3's oxygen concentrator. LPN CC stated it could have been unintentionally altered by someone who was unaware of the proper settings. LPN CC further stated that R3 required oxygen therapy for shortness of breath, but staff should ensure the oxygen was administered as ordered. In an interview on 9/18/2025 at 11:20 am, the Assistant Director of Nursing (ADON) confirmed that R3's physician's order was for oxygen at 2 LPM via a NC. The ADON stated the nurses were responsible for checking daily to ensure the flow rate was accurate.

Based on observation, record review, staff interviews, review of the manufacturer's package insert, and review of the facility's policies titled Pharmacy Services Medication Administration-General, Pharmacy Services Medication Orders, and Pharmacy Services Insulin Administration, the facility failed to ensure a medication error rate below five percent. There were two errors with 28 opportunities for two of 19 residents (R) (R4 and R71) observed, for a medication error rate of 7.14 percent. This deficient practice had the potential to result in medication not being given in accordance with the physician's orders and adversely affect R6 and R11's clinical condition. Findings Include:Review of the facility's policy titled Pharmacy Services Medication Administration-General, revised 4/15/2025, revealed the Intent section stated, To facilitate that medications are administered as prescribed, in accordance with good nursing principles.Review of the facility's policy titled Pharmacy Services Medication Orders, revised 12/31/2024, revealed the Types of Medication Orders section included, Hold Orders: Hold orders and signed and held orders are not permitted, with the exception of 'hold until medication available from the pharmacy' orders as specified in the guideline Medication Unavailable for Administration. Orders to hold a medication will be treated as an order to discontinue, and a new order must be written to resume.Review of the facility's policy titled Pharmacy Services Insulin Administration, revised 12/31/2024, revealed the Insulin Pen section included, . 5. Prime the pen and clear air from needle: a.) Turn the dose knob at end of the pen to 1 or 2 units. b.) Hold the pen with needle pointing upward. c.) Press dose knob while watching for insulin drop or stream to appear. d.) Repeat, if needed, until insulin is seen at the tip. 11. Inject the insulin by quickly inserting the needle straight in . 12. Use your thumb to press down on the dose knob until it stops (the dose window will be back at zero). 13. Needle should remain in subcutaneous tissue for 10 seconds to allow all of the medication to be administered properly.Review of the Novolog (insulin aspart) injection package insert revealed the Instructions for Use section included, Before each injection, small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units . press the punch-button all the way in . A drop of insulin should appear at the needle tip . check and make sure that the dose selector is set at 0. Turn the dose selector the number of units you need to inject. Inject the dose by pressing the punch-button all the way in until the 0 lines up with the pointer. Keep the needle in the skin for at least 6 seconds and the punch-button pressed all the way in . 1. Review of the physician orders for R4 revealed an order dated 7/25/2025 for insulin aspart [a medication used to treat high blood sugar] 100 units/milliliter (ml) (3ml) subcutaneous pen per sliding scale subcutaneous before meals and at bedtime. Observation on 9/17/2025 at 11:20 am, on the B-Hall medication cart with Registered Nurse (RN) GG, revealed the resident's fingerstick blood sugar reading was 232, indicating the resident should receive 4 units of insulin. Observation revealed RN GG prepared and administered the insulin without priming the needle after she attached it to the insulin pen. RN GG stated that the insulin pen was only primed upon initial use and did not require priming before each subsequent dose. Further observation revealed that RN GG did not hold the insulin pen in place for the recommended duration following dose delivery. The pen was held in place for approximately one second or until a click sound was heard. RN GG stated that she normally held the pen in place only until a click sound was heard. In an interview on 9/17/2025 at 11:55 am, RN GG stated that she was mistaken regarding insulin pen priming. She acknowledged that the pen should be primed before each administration. RN GG stated that failure to prime the insulin pen could result in air entering the pen and potentially cause the resident to receive an incorrect dose of insulin.2. Review of the physician orders for R71 revealed an order dated 3/27/2025 for albuterol sulfate HFA (hydrofluoroalkanes) 90 micrograms (mcg) [a medication used to treat lung conditions] two puffs by mouth three times per day. Observation on 9/17/2025 at 3:08 pm, on the A-Hall medication cart with Certified Medication Aide (CMA) HH, revealed the albuterol inhaler for R71 was not available on the cart or in the emergency medication kit. CMA HH confirmed the medication had not been administered because it was not available. CMA HH stated that the medication had been reordered the previous day but had not arrived from the pharmacy. She stated she placed the order on hold and submitted another reorder request to the pharmacy. She stated the facility's process was to place the medication on hold and wait for pharmacy delivery. In an interview on 9/17/2025 at 3:12 pm, CMA HH stated that when medication was not in stock, she would place the medication on hold until delivery. She also confirmed that the albuterol inhaler for R71 was not available on the medication cart or in the emergency kit and that placing it on hold was the facility's required procedure, and all that she was required to do.In an interview on 9/17/2025 at 4:42 pm, the Nurse Consultant stated that insulin pens should be primed with one to two units of insulin prior to each dose administration, and the pen should be held in place when administered per policy recommendations to ensure the full dose delivery. The Nurse Consultant stated that the failure to follow these steps may result in incomplete insulin administration.In an interview on 9/18/2025 at 12:46 pm, the Director of Nursing (DON) stated her expectation was for medications to be administered per the physician's order, and if a medication was unavailable, staff were expected to determine the reason with the pharmacy and notify the provider. The DON stated medications should only be placed on hold after consulting with the provider.

Based on observations, staff interviews, record review, and review of the facility policy titled Hand Hygiene, the facility failed to ensure that staff followed hand hygiene practices during the delivery of resident clothes on one of three units (Hall B) and during wound care for one of five residents (R) (R7) with wounds. These deficient practices had the potential to place the residents residing on Hall B and R7 at risk of infection due to cross-contamination. Findings Include:Review of the facility's policy titled Hand Hygiene, revised 12/27/2024, revealed the Guideline section included, Associates should use alcohol based hand rub or wash hands with soap and water for the following indications: Immediately before touching a patient. Before performing aseptic tasks. Before moving from a soiled body site to a clean body site. After touching a patient or the patient's immediate environment. After contact with blood or contaminated surfaces. Immediately after glove removal. Gloves should not substitute for hand hygiene, and hand hygiene must be performed before donning gloves and immediately after removing gloves.1. Observation on 9/16/2025 at 12:14 pm revealed that Laundry Aide EE delivered clean clothing to three residents' rooms on Hall B without performing hand hygiene upon entering or exiting any room.In an interview on 9/16/2025 at 12:18 pm, Laundry Aide EE acknowledged that she did not perform hand hygiene when delivering resident clothing on Hall B. She stated she just forgot. She further stated that there were signs posted throughout the facility reminding staff to perform hand hygiene.2. Review of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE], and diagnoses included, but were not limited to, pressure ulcer of other site stage 3.Review of the Physician's Orders for R7 revealed orders dated 7/15/2025 and 8/28/2025 to apply collagen dressing on Tuesday, Thursday, and Saturday once per day. The procedure included cleaning the right lower leg with normal saline, patting it dry, applying collagen to the open area, applying [treatment] on top, and covering it with a border dressing, related to a stage 3 pressure ulcer.Observation on 9/17/2025 at 10:04 am revealed the Director of Nursing (DON) performed wound care for R7. During the wound care observation, the DON removed her gloves and put on a new pair without performing hand hygiene between dirty and clean dressing changes. In an interview on 9/17/2025 at 10:25 am, the DON confirmed she didn't perform hand hygiene between glove changes during wound care for R7.In an interview on 9/17/2025 at 6:19 pm, the Wound Care Consultant stated that hand hygiene was required between glove changes.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled A Comprehensive Patients' Rights Program, the facility failed to ensure staff interacted with a resident in a courteous manner and allowed them access to their room for one of four residents (R) (R33) reviewed for choices out of a sample of 19 residents. This failure placed R33 at risk of their rights being violated and not upheld. Findings include: Review of the facility's policy titled A Comprehensive Patients' Rights Program, reviewed 12/29/2023 reads in part, .We believe that all staff should understand the importance of treating patients with care and respect, and honoring patients' rights to make personals choices . Review of R33's undated Admission Record, located in the resident's Electronic Medical Record (EMR) under the Resident Summary tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, type 2 diabetes, and major depressive disorder. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/5/2024 located in the resident's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. Observation on 5/7/2024 at 11:03 am revealed that R33 knocked on his room's door and asked to go inside the room. Nurse Aide Trainee (NAT) 1 opened the door and stated to R33, Go to activities, you need to go to activities and closed the door. R33's facial expression revealed he was visibly upset. Continued observation revealed that R33 waited in front of his room's door until it was opened at 11:08 am. NAT1 then stated to R33, Hurry up and get in here and get what you need. R33 then proceeded into his room. During an interview on 5/7/2024 at 11:09 am, Certified Nursing Assistant (CNA) 1 stated that she, NAT1, and CNA2 were providing care to R33's roommate when R33 knocked on the door. CNA1 stated they had been trained to tell residents they were providing patient care and to ask them to wait. CNA1 stated residents were more than welcome to come in but NAT1 just hollered for R33 to go to activities instead. During an interview on 5/7/2024 at 11:11 am, CNA2 stated she, CNA1, and NAT1 were providing care to R33's roommate when R33 knocked on the door. CNA2 stated when R33 knocked on the door NAT1 instructed R33 to go to activities. CNA2 stated after they finished providing care, NAT1 also was the one that instructed R33 to come into the room and get what he needed. CNA2 stated she did not feel NAT1's statements and tone were appropriate. CNA2 stated they had been trained to open the door and explain they were providing care. CNA2 stated if it is a resident wanting to come into their room then they just pull the curtain and allow the resident to come in. During an interview on 5/7/2024 at 11:43 am, NAT1 stated this was the first time she had experienced a resident knocking and wanting to come into their room while care was being provided to another resident. NAT1 stated when R33 knocked on their door, she opened the door and asked R33 what he needed, then instructed R33 to go to activities, and closed the door back. NAT1 stated after she was finished providing care, she opened the door and told R33 to come in. NAT1 stated she did not recall stating, Hurry up and get in here and get what you need. NAT1 also stated that CNA2 spoke to her after the interaction and told her that R33 had the right to come into the room. During an interview on 5/7/2024 at 2:01 pm, R33 stated he was trying to get into his room to get some money for the soda machine. R33 stated that was the first time he had been denied access to his room. R33 confirmed he had become frustrated at having to wait outside the door. During an interview on 5/8/2024 at 12:57 pm, the Director of Nursing (DON) stated it was her expectation the staff would have allowed R33 in his room when he wanted to go in. The DON stated there was a privacy curtain in the room that could have been pulled to allow privacy if needed. The DON also stated it was the resident's right to go in and out of their room as they please.

Based on resident and staff interviews and record reviews, the facility failed to ensure residents were as free from accidents and hazards as possible for one of 19 sampled residents (R) (R35). R35 sustained an injury when his scrotum was caught in between the toilet seat and the toilet. However, the facility did not address the resident's toilet to ensure another injury would not occur. This failure placed the resident at risk of sustaining another injury. Finding include: Review of R35's undated Admission Record, located in the resident's Electronic Medical Record (EMR) under the Resident Summary tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included absence of right leg above knee. Review of R35's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2024, located in the resident's EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Review of R35's Event-Initial Note v3.0 dated 4/25/2024 and located in the resident's EMR under the Data Collection tab documented, [R35's Name] was transferring from the wheelchair to the toilet and got their scrotum caught on a rusty screw and squashed from the toilet lid causing a skin tear to bottom of scrotum. Review of R35's Nurses Note dated 4/25/2024 and located in the resident's EMR under the Progress Notes tab documented at 10:20 pm [R35's Name] came to the nursing station and stated he went to the restroom and when transferring from the wheelchair to the toilet he got his scrotum caught on a rusty screw and the toilet lid squashed his scrotum. [R35's Name] has an abrasion noted to bottom of scrotum area cleaned with normal saline. Nurse Practitioner notified and R35 is his own responsible party. Review of R35's Nurses Note dated 5/8/2024 documented that R35 reported, Got my scrotum pinched between the toilet lid and the toilet seat.Open area noted to scrotum. Treatment Nurse and Physician made aware. The area was cleaned and dressed by a treatment nurse. The toilet was looked at by maintenance and the Director of Nursing (DON). There was no rust noted. No visible screws or nails protruding. The raised seat was removed and replaced by maintenance. During an interview on 5/7/2024 at 10:40 am, R35 stated his testicles had gotten caught and scraped by the toilet seat a couple of weeks ago, and the facility had not done anything about it. R35 stated he had a skin tear on his testicles from the incident. During an interview on 5/10/2024 at 1:13 pm, the DON stated R35 reported to nursing that he cut or scratched himself on something when he independently transferred from his wheelchair to the toilet. The DON stated nursing examined the toilet and did not see anything that could have injured R35. However, they did replace the raised toilet seat (after the surveyor had brought it to the facility's attention). The DON also stated the toilet seat should have been examined and replaced following the initial incident on 4/25/2024. The DON stated it was her expectation the nurse who completed the nursing note dated 4/25/2024 would have investigated the cause of the injury.

Based on observations and staff interviews, the facility failed to maintain a clean environment for 1 of 13 resident rooms (room [ROOM NUMBER]) on Hall A. Observations revealed that room [ROOM NUMBER] was not clean and had dried food and a sticky substance on the bedside table during the survey. This failure had the potential to place residents in an environment for use of unsanitary and unsafe equipment. Findings included: Observation on 02/07/2023 at 9:58 a.m. in room [ROOM NUMBER], the bedside table was observed to have dried, white liquid matter on the base of the bedside table and the wall next to the bed had dried matter, medium brown in color, approximately two inches in diameter. Observation on 02/07/2023 at 11:25 a.m., the wall next to the bed in room [ROOM NUMBER] had dried matter, medium brown in color, approximately two inches in diameter. The bedside table base had a sticky substance that covered the base of the legs. Observation on 02/07/2023 at 4:45 p.m., the wall next to the bed in room [ROOM NUMBER] had been cleaned; however, the bedside table still had a sticky substance on the base of the bedside table. Observation in room [ROOM NUMBER] on 02/08/2023 at 9:54 a.m., the bedside table had a sticky substance that covered the base of the table, the wall under the window had dried, brown matter splattered on it, and the fall mat next to the bed was observed to have dried, brownish/orange matter on it. Interview on 02/08/2023 at 9:58 a.m. with Laundry Aide 9 in room [ROOM NUMBER], stated she had worked in the facility for [AGE] years. She stated the rooms were cleaned daily, including sweeping, mopping, dusting, emptying trash, and cleaning the bathrooms and, then after lunch, housekeeping staff checked the rooms to make sure the trash was emptied, and the bathrooms were clean. The Laundry Aide 9 further revealed that she had not yet cleaned room [ROOM NUMBER]. Observation on 02/08/2023 at 12:53 p.m., the bedside table in room [ROOM NUMBER] still had a sticky substance on the base, and there was a dried, brown substance splattered on the wall. The fall mat had been turned upside down lying next to the bed. Observation and interview on 02/08/2023 at 2:28 p.m. with the Housekeeping/Laundry Supervisor in room [ROOM NUMBER], the fall mat was flipped over, revealing food underneath, and stuck to the fall mat. The Housekeeping/Laundry Supervisor observed the food on the floor, and under the mat, and stated that the substance on the floor and on the wall under the window appeared to be food. The Housekeeping/Laundry Supervisor revealed there was something sticky on the base of the bedside table. He stated his expectation would be for the area to be cleaned daily. He stated he was not aware of a policy regarding daily cleaning of rooms, only a list of what to deep clean when a resident left the building. Interview on 02/08/2023 at 3:55 p.m. with the Administrator, she stated it was her expectation that rooms should be cleaned daily, and walls and bedside tables should not have food, liquids, or debris on them. She stated she was unaware of a policy related to cleaning the resident rooms.

Based on observations, staff and resident interviews, record review, and a review of the facility policy titled, Care of Fingernails/Toenails the facility failed to ensure grooming assistance was provided for 1 of 3 sampled residents (R) (#54) reviewed for activities of daily living (ADLs). Observations and interviews revealed that #54 was not provided toenail care. This failure had the potential to negatively impact the resident's quality of life. Findings included: A review of the facility policy titled, Care of Fingernails/Toenails dated 12/04/2021, specified, It is the intent of this center to provide appropriate nail care to all patients. The most recent quarterly Minimum Data Set (MDS), for R#54 dated 01/02/2023, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The resident required supervision with personal hygiene. Review of the care plan for R#54 dated 03/14/2020, revealed the resident had a self-care deficit, and interventions included to assist with ADLs as needed, provide assistance with self-care as needed, and provide cues as needed. Observation and interview on 02/06/2023 at 10:04 a.m. revealed that R#54's toenails on both feet were long and sharp. R#54 indicated staff had not cut their toenails. R#54 indicated they would like their toenails to be trimmed. Observation on 02/07/2023 at 9:44 a.m. revealed that R#54's toenails remained long and sharp. Observation on 02/08/2023 at 10:34 a.m. revealed that R#54's toenails remained long and sharp. Interview on 02/08/2023 at 10:45 a.m. with a Certified Nursing Assistant (CNA) 6, revealed that the nurses and the treatment nurse were responsible for toenail care. CNA 6 stated she thought CNAs could cut resident's toenails if the resident was not diabetic. Interview on 02/08/2023 at 11:14 a.m. with a Certified Medication Aide (CMA) 3, revealed that CNAs could perform toenail care if the resident was not a diabetic; otherwise, the treatment nurse completed nail care. CMA 3 indicated toenail care was done with showers. Observation and interview on 02/08/2023 at 12:22 p.m. with the Wound Care Nurse revealed CNAs provided toenail care if the resident was not diabetic. The Wound Nurse stated that the CNAs could provide toenail care for R#54. The Wound Nurse observed R#54's feet and stated that the resident's toenails needed to be trimmed. Interview on 02/08/2023 at 2:16 p.m. with the Director of Nursing (DON), revealed she expected nail care to be provided when needed and that residents' toenails should be checked daily. Interview on 02/09/2023 at 9:26 a.m. with the Administrator, she revealed that the expectation was that all staff would be aware of care for the residents and know for whom they could and could not perform nail care.

Based on record review, staff interview, and policy review, the facility failed to ensure one resident (R) (R#2) was free from physical abuse from a sample of 9 residents. Findings include: Review of the policy titled Abuse Prohibition dated 2020 indicated the intent of the center is to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. It further noted each patient has the right to be from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Review of the Facility Incident Report Form dated 8/1/22 revealed documentation of resident-to-resident abuse. It further revealed the details of the incident as a Certified Nursing Assistant (CNA) witnessed R#1 with a pillowcase wrapped around R#2's neck stating that she would kill her. The physician, responsible party, and the police were notified. Continued review of the investigation revealed the facility determined the contributing factor for R#1's behavior is that she became upset and agitated because R#2 was calling her nonstop. R#1 stated, I have anxiety, you can't do that to people with anxiety. Review of the five-day summary conclusion and investigation revealed on 8/1/22 a CNA walking down the hallway heard and witnessed R#1 yelling I will kill you while standing over R#2. The CNA immediately entered the room and noted that R#1 had what appeared to be a pillowcase around R#2's neck. The pillowcase was immediately removed by the CNA. R#1 was immediately removed from the room and placed on 1:1 supervision until a 1013 was obtained for R#1 to be transported to the hospital for admission. R#2 was assessed and sent to the hospital for further evaluation. She was discharged back to the facility with no issues noted. Further review of the five-day summary conclusion also revealed the following steps were taken to prevent reoccurrence: R#2 is encouraged to use her call light when she needs assistance from nurses, psychosocial visits with R#2 to ensure no mental harm incurred as a result of the incident, plan of care was reviewed and revised, R#1 was removed from the facility on 8/1/22 and sent to the hospital and R#1 is being placed in another facility per her family. During an interview with CNA on 8/17/22 at 2:50 p.m., she stated on 8/1/22 she was walking down the hall and heard yelling. When she went into the room she heard R#1 saying I will kill you with a pillowcase around R#2's neck. She immediately removed the pillowcase from R#2's neck, removed R#1 from the room and notified the nurse. She stated R#1 was placed on 1:1 supervision until she was sent to the hospital later that day. She further stated that R#1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident had never tried to hurt anybody before. During an interview with the Social Services Director on 8/17/22 at 12:23 p.m., she stated R#1 had never been violent or tried to hurt anybody. She stated the resident would get anxious and did not like noise which is why she was moved to the current room because the roommates were very quiet.

Based on observations, record review, interviews, and review of the policy titled, Weekly Documentation of Wound Assessment, the facility failed to thoroughly assess and stage pressure ulcers for two residents (R) (R#6 and R#7) and failed to provide pressure ulcer treatment timely for one resident (R#7) from a sample of 9 residents. Findings include: Review of the policy titled Weekly Documentation of Wound assessment dated [DATE], revealed it is the responsibility of a licensed nurse to complete the wound assessment and document the findings, assessment and documentation are completed upon admission, readmission, weekly and as needed, the types of wounds are identified, the patient's wound is measured to include the length, width and depth, pressure ulcers are staged based upon the minimum data set (MDS) 3.0 guideline, the tissue type visualized in the wound base is identified. 1. Review of the Electronic Medical Record (EMR) revealed R#6 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 7/22/22 Significant Change Minimum Data Set (MDS) for R#6, revealed the resident had severely impaired cognition, and required total dependence from staff for bed mobility, transfers, and hygiene, nonambulatory and had one Stage 2 pressure ulcer. Review of the care plan for R#6 revealed the resident had a care plan for skin breakdown that was revised on 8/10/22, with an intervention for treatment/dressings as ordered per physician. Review of the 7/29/22 Nurse's Notes revealed that R#6 had an open pressure injury to the sacral area and would report to oncoming nurse and Director of Nursing for further evaluation and continuity of care. Review of the 7/22 Electronic Treatment Administration Record (e-TAR) for R#6 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the eTAR for R#6 revealed although a PO was obtained on 7/29/22 to treat the sacral wound, there was evidence that the treatment was not completed until three days later on 8/1/22. Review of the EMR for R#6 revealed there was no descriptive documentation of the pressure ulcer on 7/29/22 when the pressure ulcer was identified and there were no weekly descriptive wound assessments done after 7/29/22. During an observation of the resident on 8/18/22 at 12:10 p.m., the wound to the resident's sacrum had healed. During an interview with the Treatment Nurse on 8/29/22 at 11:10 a.m., she stated she had transitioned into the role as Treatment Nurse around the first of August 2022. She was only able to provide a measurement of the sacral wound dated 8/4/22 that measured 1.5 cm x 1.0 cm x 0 cm. However, there was no descriptive documentation of the wound to include, the stage of the pressure ulcer, tissue type and whether drainage was present. 2. R#7 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 7/6/22 Quarterly MDS for R#7 revealed the resident had severely impaired cognition, required total dependence from staff for bed mobility, transfer, hygiene and was nonambulatory. Review of the care plan revealed that R#7 has had a care plan dated 9/7/19 for skin breakdown: at risk for/actual with an intervention for treatments/dressings as ordered per physician. Review of R#7 Nurse's Notes dated 7/24/22, documented while providing care to resident, noted a nickel size wound to her sacral area. Wound is open and shallow with a reddish base. New treatment order received. Review of the eTAR for R#7 revealed a PO dated 7/24/22 to clean with saline or wound cleanser, dry and cover with non-adhesive foam dressing every three days. On 7/29/22 the order was changed to clean sacral area with normal saline, pat dry, apply Duoderm dressing to area, change dressing every three days or as needed. Although the treatment order changed on 7/29/22, there was no documentation wound care was done from 7/25/22 to 8/5/22. Further review of the record revealed there was no descriptive documentation of the pressure ulcer when it was identified on 7/24/22, and there were no weekly descriptive wound assessments done after 7/24/22. During an interview with the Treatment Nurse on 8/29/22 at 11:10 a.m., she was only able to provide a measurement that had been done to the sacral wound dated 8/4/22 that measured 2.5 cm x 2.0 cm x 0 cm. However, there was no descriptive documentation of the wound to include, the stage of the pressure ulcer, tissue type and whether drainage was present. During an interview with the Administrator on 8/29/22 at 5:00 p.m., she stated the previous Director of Nursing (DON) who worked from 7/13/22 through 8/1/22 was not doing the weekly wound monitoring as she was instructed to do.

Based on observation, interviews, and review of the Housekeeping policy; the facility failed to maintain the main shower room in a sanitary condition. The facility census was 76. Findings include: Review of the Housekeeping policy (revised and updated for release September 2015) revealed it is the intent of the center to maintain a clean and sanitary center that is free from odor and other environmental factors that may affect the quality of life of our patients. Procedural Guidelines: 1. This center should be cleaned in manner that is consistent with protocols and recommendations from the manufacturer of the chemicals and supplies used. An observation on 3/9/21 at 9:53 a.m. of the C-Hall shower room revealed four shower stalls with privacy curtains. In the stall on the far left side used for residents on a shower bed, there were two black cushion seats, one black mat, one torn pillow, one white bedside commode pail and a white towel that had 90% black substance. There was a black substance on the upper right ceiling as standing facing the shower stall. There was a wall unit with heavy dust hanging outside of the air flow vent. The water drain was clogged, and water was running out very slow. A Certified Nurse Aide (CNA) AA left the shower stall and got a white bed blanket to place on the floor for the slow draining water. An observation on 3/9/21 at 9:55 a.m. revealed the second smaller shower stall on the left side with a shower chair had visible hairs and wet toilet paper on the floor. There was black substance between the tile on the right side of the wall as standing in front of the shower stall. There were clear plastic wrappers on the floor on the left side as standing in front of the stall. An observation on 3/9/21 at 9:56 a.m. revealed the third shower stall to the right of the larger stall had a hole in the wall on the right side as standing in front of the stall. The left side of the shower stall had brown and black substances on the floor. Near the mat on the floor, there was one tile missing and six floor tiles with cracks. An observation on 3/9/21 at 9:57 a.m. of the wall facing the door entrance, there were three boxes of clothes and multiple items. An observation on 3/9/21 at 9:58 a.m. revealed that on the right was a tub and on the floor in front of the tub was heavy black substance on the floor tile. An observation on 3/9/21 at 9:59 a.m. of the pantry across from the tub, there was shaved hair in the sink and a hairbrush on the floor. During an interview on 3/9/21 at 12:33 p.m., CNA AA revealed that she put the white bed blanket on the floor because the water was not draining. She stated she was afraid of slipping and falling in the puddle of water. During an interview on 3/9/21 at 12:50 p.m., Resident #3 revealed that she did not want to take showers because the shower room was dirty. During an interview on 3/9/21 at 1:05 p.m., the Floor Technician BB revealed that the shower is cleaned once per week. A deep clean is a thorough cleaning. He stated that he put the bottle of Clorox in the shower room. During an interview on 3/9/21 at 1:07 p.m., the Floor Technician CC revealed that the shower room and stalls are to be cleaned by the CNAs after showering residents. During an interview on 3/9/21 at 1:10 p.m. the Housekeeping Aide DD revealed that the night shift does not clean the shower room after using the room. During an interview on 3/10/21 at 10:45 a.m., the Administrator revealed that the male residents are showered on Tuesday, Thursday, and Saturday. The female residents are showered on Monday, Wednesday, and Friday. The shower room should be cleaned daily, and this will be corrected.

Based on record review, staff interviews, and review of policy titled Fall Management, the facility failed to assure that fall assessments were completed quarterly for one of three residents (R) (#7) reviewed. Findings include: Review of the medical record for R#7 revealed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] section G revealed one-person physical assist with dressing and bathing. Review of the incident report revealed a fall for R#7 on 11/16/2020. The last Fall Assessment on file was dated 9/1/2019 with a score of 13 indicating high risk for falls. Review of the Comprehensive Nursing assessment dated [DATE] functional status did not identify any restrictions on weight-bearing status, no unsteady gait, no assistance needed moving from sitting to lying position in bed, and assistance needed from lying to sitting position on the side of the bed. There were no other Comprehensive Nursing Assessments found in the electronic medical record for R#7. During an interview on 12/11/2020 at 9:51 a.m. with Licensed Practical Nurse (LPN) AA it was reported that fall assessments are completed by nursing staff quarterly and as needed. During an interview on 12/11/2020 at 9:56 a.m. with LPN BB who reported that she thinks that fall assessments are done weekly. During an interview on 12/11/2020 at 10:02 a.m. with LPN CC who reported that the Comprehensive assessment completion correlates with whenever the MDS assessment is due and should be done quarterly, annually, and with a significant change. During an interview with the Interim Director of Nursing (DON) and the current DON on 12/11/2020 at 10:09 a.m. it was reported that the facility no longer uses the fall risk assessment, but falls are now assessed using the Comprehensive Nursing Assessment. It was further explained that the answers in the Functional Status section is what would trigger the need for a care plan related to falls. The Interim DON confirmed that no assessment for falls were completed for R#7 and she confirmed that nursing should be completing these assessments at least on a quarterly basis. The Interim DON further reported that the facility had not identified any concerns with the falls program prior to today. Fall Management Policy, updated for release February 2020: All patients will be reassessed for risk at least quarterly, annually, and with significant change in condition.

Based on observation and interviews the facility failed to assure the sanitary cleaning and storage of cigarette clips. This deficient practice affected five of nine residents that smoke. Findings include: On 12/16/19 at 2:00 p.m., there were nine residents present for the smoking break with five of the nine residents utilizing cigarette clips when smoking. One female resident was observed with the cigarette clip on lips and tongue. At the end of the smoke break all clips were placed in the smoking supply box without being cleaned and was then stored in the medication storage room. During the smoking observation on 12/17/19 at 9:15 a.m., there were nine residents present for the smoke break. There were five residents observed to be using smoking clips. One male and one female resident were observed with lips on cigarette clip while smoking. At the end of the smoking break the cigarette clips were placed in the smoking supply box without being cleaned and then stored in the medication room. During an interview on 12/18/19 at 10:57 a.m., Infection Control Specialist reported that she does not have a policy for staff to clean cigarette clips after resident's smoke and is not sure who is responsible for cleaning the cigarette clips. During an interview on 12/18/19 at 11:00 a.m. with Certified Nursing Assistant (CNA) AA it was reported that she does not clean the cigarette clips after resident's smoke, and she believes housekeeping staff is responsible for this. During an interview on 12/18/19 at 11:01 a.m. with the Housekeeping Supervisor it was reported that housekeeping does not clean the cigarette clips and has nothing to do with the smoking process. An interview was conducted with the Administrator on 12/18/19 at 11:07 a.m. and it was reported that there is no current policy or plan related to the cleaning of the cigarette clips after resident's smoke at this time. CNA BB reported on 12/18/19 at 12:12 p.m. that she does not clean the cigarette clips after resident's smoke and is not aware of who cleans the clips.

Based on observation and interviews, the facility failed to ensure the upkeep of resident wheelchairs related to dirt, dust, and hair buildup. This affected seven residents (R) (#10, #32, #40, #64, #69, #77, and #89) of 57 residents that utilized wheelchairs. Findings include: 1.On 12/16/19 at 8:51 a.m. R#32 observed in hallway with dirt, dust, and hair buildup on undercarriage and spokes of the wheelchair. 2.On 12/16/19 at 9:37 a.m. R#77 was observed sitting in the wheelchair with dust and dirt buildup. 3.On 12/16/19 at 10:56 a.m. R#89 was observed sitting in a wheelchair with a white coating on the wheels and spokes of the wheelchair. 4.During observation of smoke break from 2:00 p.m. until 2:21 pm on 12/16/19, R#77, R#69, R#40, and R#10 were observed with dirt, dust, and hair buildup on undercarriage and spokes on wheelchairs. 5.During the smoke break observation on 12/17/19 at 9:15 a.m., R#77, R#69, R#64, R#40, and R#10 were observed with buildup on spokes and undercarriage of wheelchairs. During tour with the Housekeeping Supervisor on 12/18/19 from 10:03 a.m. until 10:20 a.m. he confirmed dust, dirt, and hair buildup on wheelchairs for R#10, R#32, R#40, R#69, R#77, and R#89. He confirmed that the floor techs are responsible for cleaning wheelchairs on the hallway. He explained that one hall is cleaned per week. He acknowledged that there is some difficulty is cleaning wheelchairs as residents do not want to get out of their chairs to be cleaned. He explained that it takes two or three hours to clean the wheelchairs and this is done during the day shift. The Housekeeping Supervisor did not have any documentation supporting which wheelchairs were cleaned and which residents refused to have their wheelchairs cleaned.

Based on observation, staff interview, and review of facility policy, it was determined the facility failed to ensure meat was thawed properly for 89 of out of 92 residents who received meals prepared in the kitchen (three residents were fed via feeding tubes). The failure to thaw meat under proper conditions created the potential for food borne illness. Findings include: 1. On 6/25/18 at 9:05 a.m. the initial kitchen tour was conducted with Dietary Aide/Cook OO. A boneless pork roast sealed in plastic casing was thawing in a sink with ice visible within the package (the meat was not completely thawed), submerged in water, with water continuously running from the faucet. The surveyor's thermometer revealed the temperature was of the water was 86.6 degrees Fahrenheit (F). Dietary Aide/Cook OO checked the water temperature with her thermometer which read 86 degrees F. Dietary Aide/Cook OO stated the water temperature should be 40 degrees or colder for safe thawing. She stated the roast was for the next day and she just put it into the sink to thaw; she did not state what the specific time she put it in the sink. Review of the Spring/Summer (YEAR) week five of the cycle menu indicated garlic herb pork loin was on the menu and was served for lunch on Tuesday 6/26/18. 2. During a kitchen inspection on 6/28/18 at 9:39 a.m. with the Dietary Manager, a sealed bag of individual pieces of chicken was submerged and thawing in a large pot in the sink under running water. The surveyor's thermometer revealed the water temperature was 82.2 degrees F. The Dietary Manager also measured the temperature and stated, It is too warm, with the same temperature noted on his thermometer. He immediately obtained and poured a large quantity of ice into the water creating an ice bath solution. The Dietary Manager stated the temperature of the water for thawing should be between 32 - 41 degrees F and stated he would continuously monitor the temperature of the water to ensure it remained within the correct temperature range for thawing the chicken pieces. Review of the Spring/Summer (YEAR) week five of the cycle menu indicated southern fried chicken was on the menu for lunch on Thursday 6/28/18. On 6/28/18 at 11:09 a.m. the Dietary Manager (DM) was interviewed in the Minimum Data Set (MDS) Coordinator's office and stated, even though the water from the faucet was turned all the way to cold, it was coming out at a temperature in the 80's. The DM stated he did not know why this was happening and was in the process of investigating the cause. When asked if he was notified on 6/25/18 of the same situation when the pork roast was observed thawing in water a temperature of 86 degrees F, he stated he had not been notified of this information. On 6/28/18 at 11:50 a.m. the Dietary Manager was interviewed in the Minimum Data Set (MDS) Coordinator's office and stated he put a work order in for repair of the faucet/water temperature. Work Order #120 dated 6/28/18 at 11:47 a.m. revealed the work order was created to repair the faucet/address the water temperature. On 6/28/18 at 12:52 p.m. the Administrator was interviewed in the Minimum Data Set (MDS) Coordinator's office and stated the high temperature of the water was due to the water coming from the city at this temperature. She stated, The temperature is above 80 degrees. The Administrator stated the dietary staff was making sure the water was at an appropriate temperature for thawing. She also stated the staff was using ice to cool the water and they put a thermometer near the sink to frequently measure the temperature. At approximately 1:20 p.m., the Administrator was interviewed in the MDS Coordinator's office and stated the facility developed a document that the dietary staff were to follow immediately. The undated document titled, Re: Thawing Methods read in full, Due to the temperature of the cold water that is coming from the City Water Supply, we will be using one of the following methods for thawing. a. Under refrigerator, food items will be placed in a drip proof container b. As part of the cooking process c. In a microwave as long as food is cooked and served immediately. Review of the facility's policy titled, Food Preparation and Distribution dated (MONTH) (YEAR) indicated the intent was, to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices. Under the heading of Thawing Methods, the policy directed staff to thaw: a. Under refrigeration, food items will be in a drip proof container b. Submerged under running water at a temperature of no more than 70 (degrees) F c. Foods can be thawed in a microwave as long as food is cooked and served immediately d. Items can be thawed as part of the cooking process. Review of the Food Code, U.S. Public Health Service, U.S. Food and Drug Administration, (YEAR), Chapter 3 Food, Section 3-501.13, page 123, Thawing indicates frozen meat can be thawed under running water as follows: (B) Completely submerged under running water: (1) At a water temperature of 21 degrees C (Celsius) (70 degrees F) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5 degrees C (41 degrees F), or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5 degrees C (41 degrees F), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5 degrees C (41 degrees F);

Based on observation, record review, resident and staff interviews, and review of facility policy, it was determined the facility failed to ensure the smoking area was free of hazards during three of four observations. Staff failed to ensure all 12 residents (R#12, R #21, R #25, R #29, R #45, R #50, R #52, R#55, R #69, R #96, R #98, R #91) who smoked were fully assessed for the level of supervision required for smoking. The facility staff failed to provide assistance to one (R #69) of 12 smoking residents in properly extinguishing her cigarette prior to putting it into the cigarette disposal can, which had empty paper cigarette packs inside it. Findings include: Review of the facility document titled the Patient Smoking Guidelines policy dated (MONTH) (YEAR) under the heading of General Smoking Guidelines, indicated: Authorized fireproof ashtrays should be used in the designated smoking area. Metal containers with self-closing cover devices into which ashtray can be emptied are readily available to areas where smoking is permitted. Smoking materials should not be deposited in inappropriate containers, waste cans, on floors, on Center grounds, or any other inappropriate areas. The Patient Smoking Guidelines policy under the heading of Patient Smoking Assessment List indicated, A. The Social Services Coordinator (SSC) or Care Plan Team Representative will assess each smoker quarterly to determine the amount of assistance needed and appropriately complete and/or revised the Patient Smoking Assessment List. B. Associates responsible for the supervision of patients who smoke are responsible to inform the Care Plan Team of any changes in the level of assistance needed. 1. The smoking rules were posted at the entrance to the B Hallway on a bulletin board at a height of approximately three and a half feet. Due to the height of the posted document, the rules would have been difficult for residents in wheelchairs to read. The facility's undated Smoking Regulations posted at the entrance of the B Hallway read in full, Smoking shall be prohibited in any resident room - AT ALL TIMES. Smoking shall be prohibited in any rooms, ward or compartment where flammable liquids, combustible gases, or oxygen are used or stored and in any other hazardous location. Such areas shall be posted with NO SMOKING signs Smoking shall be prohibited in the dining room and/or kitchen area of this facility. Smoking by confused residents is prohibited except under direct supervision. All smoking articles for these residents are to be kept at the nurse's station and given out during designated smoking time in order to monitor compliance. Ash trays of noncombustible material and safe design shall be provided in all areas where smoking is permitted . The smoking area was observed on: 6/27/18 at 9:15 a.m., 6/28/18 at 9:16 a.m., 6/28/18 at 2:52 p.m., and on 6/28/18 at 3:30 p.m. The smoking area was an adjoining outdoor space (the roof was connected to the exterior of the brick building) with the roof directly above a concrete patio floor. The smoking area was open; there were no walls that enclosed the space. There were no sprinklers in the ceiling of the roof directly above the smoking area. The smoking area had seating areas with chairs and benches; and equipment consisting of a fire extinguisher, a smoking blanket, nine smoking aprons, six red cigarette butt disposal cans (each having a foot operated lid), one small can approximately 12 inches in diameter with sides approximately three inches high without a lid, and a plastic garbage can with a lid for disposal of general garbage. On top of the lid of each red can was a sign that indicated, no trash - cigarette butts only. None of the red disposal cans or the 12-inch diameter can without a lid had sand inside; cigarette butts were observed inside of all these containers. Observations on 6/27/18 at 9:15 a.m. and 6/28/18 at 9:16 a.m. revealed staff kept all the smoking materials (cigarettes and lighters) in their possession and distributed cigarettes and lit residents' cigarettes at the start of each smoking session. On 6/27/18 at 9:15 a.m. 11 residents were observed smoking. Four nursing staff members were present; they distributed the cigarettes, distributed smoking clips to some residents, assisted nine residents to put on smoking aprons, and lit residents' cigarettes for them. Most of the residents were sitting within reach of the red cigarette disposal cans. As residents finished smoking, staff removed the aprons and hung them on hooks along the wall of the building. Some residents placed their cigarette butts into the red cans independently and some residents were assisted by staff to do so. A staff member opened the can for R#69 at 9:30 a.m. and she dropped her cigarette (that was still burning) into the red can right next to her. At this time, staff were escorting other residents out of the smoking area. As the last staff member stepped out of the smoking area, the surveyor notified this person that smoke was coming out of the red can that R#69 dropped her cigarette into. The staff member opened the red can, grabbed the burning cigarette with a clip, extinguished it on the interior wall of the red can, closed the lid and exited the smoking area. Within the red can, there were two empty paper cigarette packs with numerous (more than 20) cigarette butts. The CNA did not remove the cigarette packs visible in the bottom of the can after she extinguished R#69's cigarette. Another can, approximately 12 inches in diameter with three-inch-high sides and no lid was also observed with two cigarette packs and approximately 12 cigarette butts within it. There was no sand in the bottom of either of these cans with the cigarette butts and cigarette packs. On 6/28/18 at 9:16 a.m. residents were observed smoking. The 12 inch can without a lid had two empty cigarette packs within it along with several cigarette butts. There was no sand in the bottom of can. There were approximately 15 cigarette butts on the concrete floor. At 9:29 a.m. the residents began to leave the smoking area. Staff escorted the residents out. The same red can used by R#69 on 6/26/18 had two paper cigarette packs located in the can along with numerous cigarette butts (more than 20). There was no sand in the bottom of the can. On 6/28/18 at approximately 3:30 p.m. the smoking area was checked and the red cans were inspected. Each can was empty. None of the red cans had sand inside. The Maintenance Director arrived at this time with two bags of sand he stated he just purchased the sand in town, which he poured into the cans. The Maintenance Director stated there should have been sand in the cans previously and he had been instructed by administrative staff to put sand in the cans. Interview on 6/28/18 at 1:32 p.m. with Certified Nursing Assistant (CNA) HH in the Beauty Shop revealed he was assigned to supervise smoking. He stated three staff were required to be present during all resident smoking sessions. CNA HH described the process as follows: first the smokers were assembled, then they were escorted to the smoking area, then residents were to be positioned by the red cans. Aprons were applied to residents who required them and smoking clips were distributed to residents who needed them. Cigarettes were disbursed and lit by staff. He stated residents smoked one or two cigarettes and when they were finished, the staff removed the aprons, the smoking clips, assembled the residents and escorted them back into the building. He further stated the cigarette butts were supposed to be disposed of in the red cans and staff were to make sure they were able to continue to smoke and to abide by the smoking policy. CNA HH further stated if there was garbage such as cigarette packs in the red cans, staff should remove it. He stated, Today I noticed there were some (cigarette packs) in there (cans for cigarette butts). CNA HH stated he removed four cigarette packs from two cans (the red can used by R#69 and one small can without a lid) and dumped them into the regular trash can about 30 minutes ago. He stated not removing the cigarette packs from where cigarettes were disposed of, created a fire hazard. CNA HH noted that the housekeepers were responsible for maintaining the smoking area. Interview with CNA II on 6/28/18 at 1:38 p.m. in the Beauty Shop revealed she supervised the 2:00 p.m. smoking session. She stated, I make sure there is no trash in there, the red cans, due to fire hazard. CNA II stated staff should make sure no cigarette butts that were lit were placed into the red cans. She stated, We are supposed to put it (cigarette butt) out. Interview with the Housekeeping Supervisor on 6/28/18 at 1:40 p.m. in the Beauty Shop revealed housekeeping staff was responsible for cleaning the smoking area, which included emptying the garbage and red cigarette butt disposal cans three times a week on Mondays, Wednesdays, and Fridays. He further stated, nursing staff was responsible for putting cigarette butts in the red cans and disposing of the cigarette packs properly into the designated garbage can for trash. Interview with CNA KK on 6/28/18 at 1:44 p.m. in the Beauty Shop revealed she was present at the 9:00 a.m. smoking session on 6/28/18. She stated she made sure cigarettes were completely out before she put them put in the can and made sure there was no paper in the can. CNA KK also stated, We have a trash can for paper. CNA KK stated if paper was disposed of in the ash tray/red can, it could cause a fire. She stated with R#69, she made sure her cigarette was extinguished because she typically did not smoke the entire cigarette. She stated she extinguished R#69's cigarette during the 9:00 a.m. smoking session this morning. When asked if she noticed the cigarette packs in the red can when disposing of R#69's cigarette, she said she did not. 2. Record review failed to reveal individualized smoking assessments for the identified 12 smokers. Instead the facility used a form titled, Patient Smoking Assessment List, a table in which residents' names, date of assessment, location of designated smoking area (indoors or outdoors), assistance needed for lighting the cigarette, assistance needed for holding the cigarette, assistance needed for extinguishing the cigarette, whether a smoking apron was needed, and other interventions were listed at the top of each column. The instructions on the form indicated each item was to be checked (with a check or an X) if it applied to the resident, and interventions listed were to be care planned. The rows had residents' names listed and staff were to fill in the dates residents were assessed. Review of the Patient Smoking Assessment List for all 12 residents who smoked (R#12, R#21, R#25, R#29, R#45, R#50, R#52, R#55, R#69, R#96, R#98, R#91) revealed the column for Needs assistance extinguishing cigarette was blank; this column was not filled out. R #69 had current [DIAGNOSES REDACTED]. The 5/8/18 Minimum Data Set (MDS) indicated R#69 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of five. The 5/8/18 MDS indicated the resident required extensive assistance of one staff for eating and she was totally dependent on one staff for dressing, toilet use, and personal hygiene. R#69 was coded as having limitations in range of motion to the upper extremities on one side and she used the wheelchair for mobility. On 6/26/18 at 8:32 a.m. R#69 was interviewed while she was lying in bed. She stated it was important to her to be able to smoke. She stated there were three designated smoking times daily when she could smoke if she got assistance to get up and get to the smoking area, at 9:00 a.m. , 2:00 p.m. and 6:00 p.m. The most recent Social Service Note dated 11/2/17 under the heading of Smoking, read in full, Smoking assessment was completed on 11/2/2017. Resident continues to smoke with safety and doesn't require any safety devices. Care plan has been reviewed accordingly. The most recent Patient Smoking Assessment List dated 6/1/18 indicated R#69 smoked outdoors, needed assistance lighting the cigarette, used a clip for holding the cigarette, and needed a smoking apron. The column for needs assistance extinguishing cigarette was blank/not filled out. R#69's care plan dated 4/28/18 documented interventions included supervised smoking, use of smoking apron and clip, and provision of assistance as needed. In an interview on 6/28/18 at 11:50 a.m. with the Director of Nursing (DON) in her office, she was notified of the empty cigarette packs being in the red cans on two consecutive days (6/27/18 and 6/28/18) that were supposed to be for cigarette butts only. She stated she did not know why the empty cigarette packs were in the cans for cigarette butts, and verified they should be in separate containers. The DON stated she would check it out. When asked if there were individualized smoking assessments, she stated smoking assessments consisted of the Patient Smoking Assessment List that was completed quarterly for all smokers. Interview with the MDS Coordinator on 6/28/18 3:59 p.m. in the Activity Director's Office revealed she developed the residents' care plans for smoking. She stated she added interventions such as whether residents needed a clip for holding the cigarette, or a smoking apron to the care plans. She stated social service staff completed the smoking assessments and she obtained the interventions for the care plan from the smoking assessment. Interview with the Social Service Assistant on 6/28/18 at 4:59 p.m. revealed the facility allowed smoking for residents who were grandfathered in because the facility had become a non-smoking campus and new residents were not allowed to smoke. The Social Service Assistant stated she completed smoking assessments by observing and talking to residents during scheduled smoking sessions. She stated she assessed half of the residents at a time (approximately six residents) during a smoking session, and this was done on a quarterly basis. She stated, I don't let them know I am evaluating them. I just watch and do about half of the residents at a time. She stated, I just look for changes. The Social Service Assistant stated she lets the nurse know if she saw any changes and wrote an annual progress note with smoking information which included information regarding whether the resident could smoke safely, use the ash tray, and whether a clip was needed for residents who had difficulty holding cigarettes. When asked about the column on the Patient Smoking Assessment List regarding residents' ability to extinguish cigarettes, she stated, We don't do the assessment of extinguishing the cigarette. The Social Service Assistant stated when she started in her position approximately 10 months ago, that section had not been filled out. She stated she followed the protocol that was in place when she started. When asked if any residents needed assistance with extinguishing cigarettes, she stated R#12 needed assistance and R#69 needed assistance at times. When asked about residents being notified of smoking rules, she stated, I am not sure if they are given the rules. I haven't given them any rules. The Social Service Assistant stated she would look into this and returned approximately 15 minutes later and stated smoking rules were not given to the residents; however, they were posted.

Based on observation, record review, interview, and review of facility polices it was determined the facility failed to provide a safe environment for two residents ( R) from one resident (R #66 ) with known behaviors of touching, pulling and grabbing other residents. This failure affected R #42 and R #73 from a sample of 22 sampled residents. Findings include: Review of the facility's document titled Grievance Policy/Abuse Prohibition Policy dated (MONTH) (YEAR) revealed: Definition. Physical abuse includes hitting, slapping, pinching, and kicking . Mental Abuse a. Humiliation, harassment, threats of punishment or deprivation . Once an injury or event is identified as suspicious and may constitute abuse, the center will follow the investigation procedures. B. Identification of patients whose behavior is abusive to other patients .b. Patients who have displayed or attempted to display abusive behavior toward other patients 2. From the assessment, intervention strategies will be developed on the care plan or behavior management plan to prevent occurrences including monitoring for factors that trigger abusive behavior for this patient . 1. Record review revealed R #66 (aggressor) was admitted to the facility (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Review of R #66's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that he was coded as severely cognitively impaired and noted to have had one to three days of physical behavioral symptoms and other behavioral symptoms. Review of the Care Area Assessment Summary (CAAs) indicated R #66 triggered for behavioral symptoms. Review of R #66 (aggressor) most recent MDS dated [DATE] assessed the resident with moderately impaired cognition with physical behavioral symptoms that put others at significant risk for physical injury and intrude on the privacy and activity of others. The resident had no impairment of upper and lower extremities and utilized a wheelchair for mobility. Review of R #66's behavior care plan dated 4/24/17 and effective on 2/15/18 revealed: Problem- that R #66 grabbed at staff and peers. He had a history of [REDACTED]. Resident #66 got anxious when his surroundings were loud. He pulled on other residents to get their attention. He had a history of [REDACTED]. R #66 acted out when provoked by roommates. Additionally, R #66's water cup was removed from his bedside because he threw his water at other residents. Goal- R #6 will not injure himself or others during the review period. Interventions: Notify MD (doctor) of any new behaviors or exacerbation of behaviors. Pharmacy Consult for review of medications. Talk with resident in a calm reassuring voice. Direct him away from cause of behavior. Assess for physical, situational, occurrences that may cause the inappropriate behavior (4/24/17). Observe for behavior and concerns and attempt to divert. Praise for involvement and socialization. Praise for his attempt to console others (7/18/17). Redirect resident when pulling at others (9/14/17). Involve him in group events and escort him from the group when having verbal and physical behaviors that are disruptive to the group. Offer him in room activities such as music, wheelchair rides outside (1/14/18). Resident goes to Director of Nursing's office to talk and de-stress when behaviors occur (1/26/18). Assess resident for likes and dislikes for different activities (3/15/18). Consult psychiatric services, reassess behaviors, assign to a staff member if he is awake and, in his wheelchair, (6/25/18). 2. Review of the face sheet for R #42 (recipient) documented the resident was admitted into the facility (MONTH) 2013 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) for R #42 dated 3/26/18 revealed the resident was coded as cognitively intact with a Brief Interview for Mental Status score of 12. The resident was coded as resisting care four to six days but no other behaviors. The resident had no impairment of upper or lower extremities and utilized a wheelchair for mobility. Review of the Care Area Assessment summary (CAAs) for R #42 indicated that activities of daily living/rehabilitation potential, psychosocial well-being, mood state, behavioral symptoms Review of the current care plan for R #42 dated 4/13/18 revealed plans that included: Mood State- 1/6/18- Resident has a [DIAGNOSES REDACTED]. Remains on antidepressant medication. Attention seeking, will fabricate stories so she can spend time with Administrator; she will prefer not to take her medication and showers if she cannot have her way; she has a history of self-inflicted abrasions to arms and abdomen; false accusations against staff; attention seeking behavior; takes medicine from certain nurses because some nurses she do not like and will fabricate stories, manipulate behavior and will try to manipulate new employees. Review of the R #42's SBAR (Situation, Background, Assessment, Review) Communication Form and Progress Note for RNs/LPN/LVN (Registered Nurses, Licensed Practical Nurses, Licensed Vocational Nurses) dated 4/23/18 indicated that R #42 was choked by another resident on 4/23/18. According to the SBAR R #42 had not been choked by the other resident before 4/23/18. R #42's blood pressure was recorded as 138/86, pulse was 61, respiratory rate 20, temperature 97.8 and pulse oximetry was 91% on room air. According to the SBAR documentation there was no change in R #42's mental status, functional status, behavior or respiratory status. Review of the PAR(Patients at Risk) review dated 5/11/18 indicated the area of clinical review was safety. The situation described was that R #42 was choked by another resident (R #66) when she was sitting by the nurse's station during the night. The residents were separated by staff. Review of the additional notes in the PAR Review indicated that R #42 was already receiving psychiatric services and that staff were educated on keeping residents separated. On 6/26/18 at 11:30 a.m. a survey team member was informed during the Resident Council meeting that R #66 (aggressor) put his hands on R #42's throat as if to choke her a couple months ago. The facility was unable to provide documentation that R #42's care plan was developed or revised to address the attempted choking incident by R #66 (aggressor) that occurred on 4/23/18. Interview with R #42 (recipitant) in the hallway near the Minimum Data Set (MDS) Director's Office on 6/27/18 at 2:41 p.m. when asked about the choking incident (on 4/23/18) revealed that R #66 (aggressor) was always touching female residents. She recalled that R #66 had one hand on her leg and the other hand on her throat and she was screaming turn me loose. One of the Certified Nursing Assistants HH got him off of her. Further interview with R #42 revealed that she had no bruising or swelling or injury from being choked by R #66 however, she was afraid of him. R #42 stated that she told a Registered Nurse (RN), the Director of Nursing (DON) and the Administrator that she was afraid of R #66. R #42 said that she could not recall the date that she told the RN, DON and Administrator that she was afraid of R #66. She was told to watch him (R #66) and tell him 'no but that did not work. R #42 said that she has not seen the psychiatrist since the choking incident and does not see a psychologist. R #42 added that R #66 touched her early on 6/27/18. She said that she was in line in the hallway to get a bath. R #66 touched her leg. She called for CNA HH to help her and he looked at R #66 in the face and told him No. CNA HH then told her to say No. Interview with CNA HH, in the dining room on 06/27/18 at 3:00 p.m. revealed that he saw R #66 (aggressor) reach out for R #42 when she was sitting against the wall in line waiting to get a shower this morning. He (R #66) reached out towards her and she said No. CNA HH reported that he told R #66 that she said, No. Do you know what that means when someone says, no. R #66 nodded his head yes. CNA HH said that he thought R #66 understands what you tell him in the moment but quickly forgets, within minutes. CNA HH then turned R #66 around and he went back towards his room. CNA HH added that I'm not exactly sure, but I think he got up on his own, between 6:30 a.m. and 6:45 a.m. (he is able to get up unassisted). CNA HH said that he kept an eye on R #66 basically one on one today. CNA HH also said that on yesterday the staff were given the assignment for one on one for R #66 verbally. The CNAs working his hall were told to monitor him closely. Interview with the Social Services Assistant GG in her office on 06/27/18 4:56 p.m. revealed that she was aware of the incident between R #42 and R #66 but was not certain what was done for R #42 after the incident. Social Services Assistant GG stated that the altercation was not put in the system as a complaint or a grievance. The Social Services Assistant also stated that she was unaware that R #42 was afraid of R #66. Social Services Assistant GG further stated that she would normally try to keep them separated. She said that staff use redirection, dining at different times, activities at different times to prevent resident to resident altercations. Interview with Social Worker (SW) LL in the nurse's station on 6/28/18 9:05 a.m. revealed that she interviewed R #42 this morning. R #42 had not informed the facility of her fear of R #66. SW LL said that R #42 was encouraged to speak to her psychiatrist. R #42 said this morning that she was not afraid of him (R #66) now that she knows that the facility was aware of her fear and were taking care of him. Interview with the Administrator 6/28/18 4:43 p.m.in her office revealed that the only investigation notes regarding the choking episode between R #42 and R #66 is in R #42's health record. This incident was not investigated or reported to the state. The Administrator said that she would be notified of instances of resident to resident abuse and any new interventions would be discussed in the morning meetings and the weekly PAR meetings. 3. Record review revealed R #73 was admitted to the facility in (MONTH) 2012; her [DIAGNOSES REDACTED]. Review of the 5/10/18 Quarterly Minimum Data Set (MDS) under Section B - Vision, Hearing and Speech, revealed the R #73 had adequate hearing and clear speech. She was coded as usually understanding and usually being understood. Under Section C - Cognitive Patterns, she was coded with modified independence in decision making. The Brief Interview for Mental Status test was not completed. The resident was coded as knowing the location of her room, staff's names and faces, and that she was in a nursing home. Under Section G - Functional Status, the resident was coded as being totally dependent on staff for personal hygiene, toilet use, and transfers and requiring extensive assistance for mobility and dressing. The resident was coded as requiring limited assistance for locomotion on and off the unit. R #73 was coded with limitation in range of motion to both sides of the upper and lower extremities and using a wheelchair for mobility. Per Section K -Nutritional Status, the resident was small in stature with a height of 3 feet 6 inches and a weight of 93 pounds. Observation of the B Unit on 6/25/18 at 11:30 a.m. revealed R #73 was heard repeatedly yelling Stop, (R #66)! R #66 (aggressor) was observed to hit, push and thump R #73's helmet. R #66 would not stop as requested, and R #73 could not prevent him from moving her helmet to the back of her head. Nursing staff were alerted to the altercation (by Surveyor intervention), and upon arrival, Licensed Practical Nurse (LPN) AA redirected R #66 and attempted to separate him from R #73 by backing up his wheelchair. R #66 stood from the wheelchair and grabbed R #73's left foot, removed her sock and squeezed the toes on R #73's left foot. LPN AA verbally and physically prompted R #66 to sit in his wheelchair, and after several prompts R #66 complied. Interview on 6/25/18 at 11:35 a.m. in the hallway of B Unit, LPN AA stated R #66 exhibited this type of behavior daily. The nurse stated staff were often separating him from altercations with other residents, and from going into other residents' rooms uninvited. The nurse stated R #66's behavior was difficult to manage. Interview on 6/25/18 at 11:42 am in the hallway of B Unit, R #73 stated R #66 touched her every day; mostly on her helmet and feet. She said it made her angry. A review of R #73's care plan revealed it did not include interventions to protect R #73 from R#66. During a family interview on 6/26/18 in a resident's room from 9:09 a.m. - 9:40 a.m. R#66 (aggressor) was wheeling himself down the C Hall in his wheelchair. The surveyor was sitting in a chair facing the interior of the room, near the door from the hallway into the room. The door was open. As the surveyor turned and looked over her shoulder, R #66 was wheeling himself into the room towards the surveyor, with a fixed look of determination. The resident reached towards the surveyor's chair and struggled to grab the surveyor. The surveyor scooted her chair approximately 18 inches forward, while three nursing staff grabbed R #66's wheelchair from behind and struggled to pull the wheelchair backwards out of the room. After a few seconds, with the resident lunging forward and attempting to reach the surveyor's chair, staff wheeled him out of the room and down the hall. On 6/26/18 at 10:21 a.m. R #73 was interviewed in her room and the resident stated (R #66) touches my arms and legs. I don't like to be touched. Every time he sees me, he touches . I've tried to do something about it. It makes me angry. I tell him to stop, but he won't. R #73 stated it happened in the hallway. The resident also stated that she wears a helmet due to [MEDICAL CONDITION] activity. She stated that was why she kept her door shut. The resident stated she could not get R #66 off her and stated, Staff have to get him off me. R #73 also stated the Director of Social Services and the Administrator came and talked with her after the incident that occurred on 6/25/18 (when R #66 pulled her helmet off the top of her head and her sock observed by the surveyor). R #73 stated it happened again this morning, on 6/26/18 when R#66 (aggressor)was going down the hallway in his wheelchair and he grabbed her. She stated she yelled at him this morning that she did not like to be touched. She stated the Activity Assistant got him off her. R #66 stated she felt threatened by R #66 and did not feel safe. Although R #73 stated she had not officially reported the incidents with R #66 to staff, staff had to pull R #66 off her repeatedly (indicating staff were aware) and she expressed her anger and frustration to them when this occurred. On 6/26/18 at 11:38 a.m. the Activity Assistant was interviewed and stated she was wheeling R #66 down the C Hall to bring him to activity room (located at the end of the C Hallway) this morning. She stated R #66 grabbed R #73's arm and R #73 yelled, Don't touch me! The Activity Assistant stated, I got him (R #66) off her (R #73). The Activity Assistant stated R #66 was, touchy, feely and reported some of the residents did not like to be touched. The Activity Assistant stated R #66 did not target specific individuals and instead, will grab at staff, anyone. The Activity Assistant stated staff had to intervene to pull R #66 off her a few times. When asked how staff were to manage R#66's behavior, she stated they redirected him. When asked if there was any plan following the incident on 6/25/18, she stated she was not aware of any new interventions. The Social Service Director was interviewed on 6/26/18 at 11:23 a.m., stating she had been in her position for two weeks. She verified that she and the Administrator interviewed R #73 together on 6/25/18 following the surveyor bringing the incident between R #66 and R #73 to their attention. The Social Service Director stated R#73 told she and the Administrator it had happened before (R #66 grabbing her), but R #73 had not reported it. The Social Service Director stated R #66 was not aware of what he was doing. She stated the staff were supposed to redirect R #66 as needed, and staff were trying to do one on one supervision with him based on the incident on 6/25/18 with R #73. The Social Service Director stated R #66 was hard to redirect; the staff did their best to separate him from other residents. The Social Service Director stated sometimes R #66 listened and sometimes he did not. Although LPN AA intervened and pulled R #66 off R #73 on 6/25/18, the Social Service Director stated the staff did not know about the incident on 6/25/18 between R #66 and R #73. The Social Service Director stated an investigation was being conducted and the incident occurring on 6/25/18 had been reported to the State. The Social Service Director stated she completed a behavioral assessment on R #66 yesterday and the psychiatrist had been called. In an interview on 6/26/18 at 3:40 p.m. the Administrator stated the incident between R #66 and R #73 was reported to the State yesterday. The Administrator stated any incident prompted an investigation to be completed. She stated the physical, mental, and emotional issues occurring with an allegation were reported to the State. The Administrator stated she was aware of previous incidents between R #66 and other residents including R #12 and R #56 and stated investigations had been conducted. The investigations involving R #66 were reviewed by one of the surveyors. In an interview on 6/26/18 at 3:52 p.m. Maintenance Staff BB stated he observed incidents with R #66 and staff as well as incidents with R #66 and other residents. He stated a nurse walked past R #66 recently when R #66, with a fixed look, reached and grabbed at the nurse. He stated he distracted R #66 and the nurse scooted around the resident. He stated he had intervened previously between R #66 and R #73. Maintenance Staff BB stated, He (R #66) goes where he wants and stated he heard R #73 yelling Get out (R #66) when R #66 was in R #73's room. He stated he had removed R #66 from R #73's room. Maintenance Staff BB stated he was aware of two instances when R#66 went into R #73's room and had to be removed. Maintenance Staff BB stated R#66 went into other residents' rooms as well. Maintenance Staff BB stated he did not think R #66 targeted specific individuals. In an interview on 6/26/18 at 3:56 p.m. CNA PP stated R #66 wandered in and out of residents' rooms. She stated R #66 could walk and she had seen him touch and grab residents. She stated she had reported this to the nurse on duty. CNA PP stated she was aware of incidents between R #66 and R #73 and stated she had heard R #73 yell at R #66 to leave her alone. In an interview on 6/26/18 at 3:59 p.m. the Director of Nursing (DON) stated she had never seen R #66 touching R #73 but had been told about it once or twice. The DON stated R #66 was not mean and wanted attention. She stated R #66 liked to hug a lot. The DON stated she was aware of incidents between R #66 and other residents. The DON stated staff were to keep R #66 away from R #73. The DON stated the facility was looking for placement for R #66 in another facility. In the meantime, staff were to used behavior modification such as providing him with favorite beverages when his behavior was good, and staff were to use redirection. On 6/28/18 11:30 a.m. R #73 was interviewed again in her room. She stated that now she has a new Velcro stop sign across the door into her room, which was observed to be in place. R #73 stated she had not had any more problems with R #66 so far. On 6/28/18 at 4:38 p.m. R #73 was in her wheelchair in the hallway outside her room and stated she hoped the Velcro strap would continue to work to keep R #66 out of her room. The investigation documents provided to the surveyors included the 3/14/17 Treatment Service: PASRR Level II document which indicated R #66 was diagnosed with [REDACTED]. The question, Does this individual demonstrate severe maladaptive behavior (s) that place the health and safety of this individual or others in jeopardy? was checked Yes with the description of the behaviors documented as aggressive behaviors when frustrated. The Facility Incident Report Form indicated the incident on 6/25/18 was reported to the Georgia Department of Community Health on 6/25/18. The type of incident was specified as Resident to Resident Emotional Harassment. The Administrator presented a handwritten statement dated 6/25/18, based on a conversation with the Administrator and Social Service Director and R #73. The documented indicated R #66 touched R #73's helmet, her foot and took her sock off on 6/25/18 and he did it a lot. R #73 stated she did not like to be touched. R #73 stated she had not told any of the staff about it. R #73 stated she did not know why he picked at her, but she wanted him to stop. R #73 stated she wanted the staff to keep R #66 away from her. R #73 was reassured the staff were working on keeping R #66 away from her and she was encouraged to let staff know if it happened again. The handwritten statement failed to indicate specifically how the facility staff were going to protect the R #73 from the aggressive behaviors of R #66. Cross Reference to F 740

Based on record review, interview, and review of facility policy, the facility failed to revise the behavior and [MEDICAL CONDITION] medication care plans for one (1) of 22 sampled residents' (Resident (R) #66). The findings included: Review of the facility's policy titled Developing an Interdisciplinary Care Plan - At a Glance policy (undated) revealed the following: 1. c. - Interventions should be specific individualized approaches that staff will take to assist the resident to achieve the identified goal. 1. d. - Discipline assigned to complete intervention - each intervention must have a discipline assigned to complete that task. The interventions must be communicated to the direct care staff that is to complete the task. 1. e. - Evaluation - the effectiveness of the care plan must be evaluated and modified as necessary. If the goal is not met, the plan should be adjusted. The goal date must be updated with each review. 8. - Consultation recommendations should be considered for incorporation into the plan of care. These may include psychiatric. Review of R #66's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed an admitted (MONTH) (YEAR). R #66 had [DIAGNOSES REDACTED]. R #66 was coded as severely cognitively impaired and noted to have had one to three days of physical behavioral symptoms and other behavioral symptoms during the seven-day assessment period. The resident was administered antipsychotic, antianxiety, and antidepressant medications for seven days during the assessment period and received no psychological therapy. Review of R #66's Quarterly MDS dated [DATE] revealed during this assessment period, the resident was coded as moderately cognitively impaired; and had physical behavioral symptoms for one to three days; other behavioral symptoms one to three days; put others at significant risk for physical injury; significantly intrudes on the privacy or activity of others; significantly disrupts care or living environment. R #66 had no impairment of upper or lower extremities and utilized a wheelchair for locomotion on the unit which required the supervision of one staff. The resident was administered antipsychotic, antianxiety, and antidepressant medications for seven days during the assessment period and received one day of psychological therapy for at least 15 minutes within the last seven days. Review of R #66's Clinical [DIAGNOSES REDACTED].#66 had [DIAGNOSES REDACTED]. Review of R #66's physician's orders [REDACTED]. Review of R #66's clinical record revealed he had the following documented behavioral incidents: 3/27/18 - (Interdisciplinary (IDT) Progress Note) - R #66 is awakened easily and moves thru out hall with his feet while he's in wc (wheelchair). He approaches women residents when they don't want him to. Easily diverted to something else. 3/31/18 - (IDT Progress Note) - R #66 grabbed another resident by shirt, pulled resident and w/c over without provocation. Notified family and MD, new order for UA (urinalysis) C&S (culture and sensitivity) d/t (due to) increased behaviors, anxious and uncooperative. 4/3/18 - (IDT Progress Note) - Pt. (patient) out of room a while before breakfast. Up and down the hall with people saying, don't touch me. I gave his meds which distracted somewhat. He returned to his bedroom and ate well. In and out of bed at will. 4/23/18 - (SBAR (Situation, Background, Assessment, Review)) - Resident came down B Hall to A Hall in front and started choking another resident. Resident approached another resident and put right hand around her neck and resident began to scream until we were able to stop him. The resident's primary care physician (PCP) was notified on 4/23/18. There was no documentation to indicate the resident's psychiatrist was notified of the incident. 5/1/18 - (Patients at Risk (PAR) Review) - R #66 choked another resident while she was sitting at the nurse's station. Residents had to be separated by staff. Resident has a history of grabbing at staff/residents. He is not easily redirected. Resident also has a history of altercations with other residents. According to the document R #66's care plan was revised and updated. 5/14/18 - (SBAR) - altercation. Resident entered another resident's room to talk to resident in middle bed. Other resident accidently scratched him when trying to remove him from room. Then R #66 yelled Please don't hurt me. Scrape to right side of cheek/face with two ( 2) welts, two (2) centimeters (cm) long. Scratch to right side cheek - no treatment necessary - clean leave open to air. The resident's primary care physician (PCP) was notified on 5/14/18. There was no documentation to indicate the resident's psychiatrist was notified of the incident. 5/16/18 - (IDT Progress Note) - resident alert, took meds, scratch to right side cheek dry, needs frequent redirecting, monitoring for touching others and entering other resident rooms. 6/20/18 - (IDT Progress Note) - R #66 walking in hall on B Hall without wheelchair. Nurse was redirecting resident to get his wheelchair, and R #66 lunged at nurse stating, I want pretty girl. Maintenance Staff (MS) BB helped redirect patient because nurse was unsuccessful.Resident was verbally redirected. 6/23/18 - (SBAR) - R #66 was pushed to the floor- wanders into other residents' rooms uninvited. Another resident pushed resident against a table that caused an indention(temporary) and abrasion without broken skin to the upper mid back. No broken skin - rednesswith indentation on mid upper back. Monitored throughout the day, no changes in condition or c/o (complaining of) pain, ambulatory and frequently reminded resident is not to go into the rooms of others without being invited. The resident's primary care physician (PCP) was notified on 6/23/18. There was no documentation to indicate the resident's psychiatrist was notified of the incident. Review of R #66's Psychiatric Medication Evaluation dated 2/18/18 revealed the following: Presenting Problems and interval history: Remains regressed, intrusive, impulsive and unsafe. Fall risk, aggravates peers to point of getting hurt and in general population - grabs females and goes in their rooms without understanding. Mental status exam: Can't control himself well, resists redirection at times. Description of session: Can't understand his problem even when reviewed. Laughs with MD (doctor) about his behaviors. Recommendations for PCP (primary care physician)/Facility Staff: Discussed with numerous staff, his risks with intrusiveness impulsivity and unsteady gait make interventions needed now for safety. Increase Klonopin to 0.5 mg (milligram) t.i.d (three times a day), add [MEDICATION NAME] 50 mg q (every) pm (night). Review of R #66's behavior care plan initiated on 4/24/17 revealed: Problem (Onset date: 4/24/17; Effective date: 2/15/18): Resident has a [DIAGNOSES REDACTED]. He grabs at staff and peers. He doesn't like things out of place and he doesn't like doctors, history of hitting and kicking and history of cursing and saying shut up, staff reports he gets anxious when his surroundings are loud. Pulls on other residents to get their attention. Resident started punching another resident and fell to the floor, (R #66) has a history of grabbing a staff members clothes and face swinging hands and hit staff member in the face; goes into other residents' rooms uninvited; touches other residents and staff inappropriately. 3/7/18 - sister-in-law states he hasn't been told no and she will try to come in today to talk with him; 3/15/18 - (R #66) acts out when his roommates provoke him; 3/20/18 - Resident is not to have a water cup at bedside (due to) d/t throwing it at peers; 6/25/18 - picking at another resident by touching her on the head, pulling socks off, touching her feet, he went into another resident's room. Goal: Resident will not injure self or others as a result of behavior during the review period (8/31/18); 3/15/18 - To observe residents and to ensure they are following safety guidelines; 3/20/18 - Resident will not injure others as a result of behavior Interventions: 4/24/17 - notify MD for any new behaviors or exacerbation of behaviors/pharmacy consult for review of meds/talk with resident in a calm and reassuring voice; direct resident's attention away from cause of behavior if possible/assess for possible physical causes of behavior/assess for situations/occurrences that cause inappropriate behavior. 7/18/17 - Observe for behaviors and concerns and attempt diversions to alter praise for involvement and socialization and his attempts to console others; 9/14/17 - redirect resident at pulling on others; 1/14/18 - involve in group events escort from the group when verbal and physical behaviors disrupt the group and offer room activities 1:1 offer music, w/c rides outside, variety of settings; 1/26/18 - resident goes to DON (Director of Nursing) office to talk and distress (de-stress) when behaviors occur; 3/15/18 - assess residents for likes and dislikes for different activities to keep resident occupied; 3/20/18 - water cup removed - resident transferred to another room; 6/25/18 - consult psychiatric services/reassess behavior/assign to a staff member if he is awake in wheelchair. R #66's behavioral care plan was not revised/updated after R #66's psychiatrist recommended facility staff develop and implement interventions to address the resident's intrusive/impulsive behavior on 2/18/18; the behavioral care plan was not revised/updated after R #66 pulled over a resident in their wheelchair on 3/31/18; it was not updated/revised after R #66 choked another resident on 4/23/18; the behavioral care plan was not updated/revised after R #66 sustained minor injury to the face after entering another resident's room on 5/14/18; and the behavioral care plan was not updated after wandering into another resident's room and sustaining minor injury to his back on 6/23/18. Review of R #66's [MEDICAL CONDITION] drug usage care plan dated 4/24/17 revealed: Problem: Takes [MEDICAL CONDITION] medication; takes antidepressant, antianxiety, and antipsychotics. Has [DIAGNOSES REDACTED]. Goal: Resident will not develop any significant side effects related to [MEDICAL CONDITION] drug use during the review period (8/31/18). Interventions: 4/24/17 - Observe and report any decline in functional status; 4/24/17 - observe and report signs and symptoms of postural [MEDICAL CONDITION] (dizziness, [MEDICAL CONDITION] upon standing, [MEDICAL CONDITION], falls); 4/24/17 - observe for involuntary movement disorders; 4/24/17 - consult with pharmacy or doctor for medication review; 4/24/17 - monitor and document frequency and behaviors patient is exhibiting; 4/24/17 - observe for increased constipation, [MEDICAL CONDITION], dehydration, or dry mouth; 4/24/17 - give medication as ordered; 4/24/17 - monitor labs as ordered and report to doctor as needed. R #66's [MEDICAL CONDITION] drug usage care plan was not updated/revised after it was initiated on 4/24/17. Review of R #66's Behavior Monitoring Record for (MONTH) (YEAR) revealed there was no documentation for any target behaviors between 6/1/18 through 6/28/18. The forms were blank, and there was no documentation to indicate if any target behaviors occurred. Interview on 6/25/18 at 11:35 a.m. in the hallway of B Unit, LPN AA stated R #66 exhibits this type of behavior daily. The nurse stated R #66's behavior was difficult to manage, and the nurse was unsure of the interventions listed in his care plan. Interview with the Director of Nursing (DON) in her office on 6/28/18 at 8:46 a.m. revealed that the 3/15/18 intervention noted in the behavioral care plan should have been done by the Activities Director and then added to the resident's care plan. The DON confirmed there was not a record this intervention was completed by the Activities Director. The DON said R #66's behavior has been going on for a couple of months, and the interventions to address his behavior of wandering into others' rooms was to go up to him and calmly tell him he's not allowed to be in that room, and then redirect him with food/drink/different place. The DON stated, when in the hallway R #66 can roam - he goes up and down halls and talks to everybody. The DON said R #66's care plan did not address redirecting the resident before he entered into other residents' rooms. Interview on 6/28/18 at 5:30 p.m. with MDS Coordinator in the Activity Director's office revealed that she initiates residents' care plans and the interdisciplinary team updates/revises the plan as needed. The MDS Coordinator said Social Services was responsible for acting on the recommendations from the psychiatrist. Interview on 6/28/18 at 5:45 p.m. in the Social Services office with the Social Services Assistant (SSA) revealed their office received the residents' psychiatric consultations and then place them in the chart for nursing to look at. She said social services did not update the care plan in response to the psychiatric recommendations.

Based on record review and interview, it was determined the facility failed to provide appropriate incontinence services for one of 22 sampled residents (Resident (R) #15). A physician ordered urine specimen was not collected when R #15 was assessed to have blood in his urine. The findings included: Review of R #15's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R #15 scored 13/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating the resident was cognitively intact. R #15's bowel and bladder status were not rated; resident had a catheter and ostomy bag. R #15 was not administered antibiotics during the assessment period. Review of R #15's physician's orders [REDACTED]. Review of R #15's recapitulated physician's orders [REDACTED].#18 10 cubic centimeters (cc) bulb to bedside drainage bag due to [MEDICAL CONDITION] bladder with retention/change catheter as needed for malfunction or inadvertent removal. Review of R #15's urinary care plan (original date 9/14/15 and an effective date of 5/1/17) revealed R #15 requires a suprapubic catheter r/t [MEDICAL CONDITION] bladder. History of urinary tract infection [MEDICAL CONDITION] and at risk for future UTI's. Goal -resident will be free of complications associated with need for catheter during the review period (7/31/18). Interventions: 9/14/15 - provide catheter care, anchor/secure catheter as allowed, change catheter as indicated, observe output, position drainage bag below the level of the bladder, keep bag and tubing off the floor, observe and report any signs and symptoms of UTI, provide family and resident education, and utilize closed system as indicated. During an interview conducted at the nurse's station with the Residential Care Coordinator (RCC) on 6/28/18 at 2:00 p.m., the RCC revealed the UA was not collected as ordered on [DATE]. Interview on 6/28/18 at 3:15 p.m. with the Director of Nursing (DON) at the nurses' station revealed that after an order for [REDACTED].#15, and the specimen should have been collected on the day of the order. The DON confirmed the resident had a catheter, and the urine specimen could have easily been obtained from the catheter bag. When asked about follow-up to ensure physician's orders [REDACTED]. The DON stated, it fell through the cracks. Interview on 6/28/18 at 3:25 p.m. with R #15 in the resident's room revealed he had pressure in his lower abdomen and he suspected he had a UTI. He stated he has had symptoms for the past week. He confirmed a specimen was collected earlier this afternoon (on 6/28/18). Follow-up interview on 6/28/18 at 4:10 p.m. with the DON at the nurses' station confirmed the resident's physician's orders [REDACTED].

Based on observation, interviews, clinical record reviews and review of facility policy, it was determined the facility failed to ensure one (1) of 22 sampled residents (Resident (R) #66) received necessary behavior health services to address significant behavioral incidents and failed to develop and implement non-pharmacological interventions as recommended by R #66's psychiatrist. The findings included: Review of the facility's document titled Behavior Health policy (undated) revealed the procedural guidelines were as follows: 2 c. developing and implementing non-pharmacological interventions based on the needs of the individual patient; 3. Patients who display or who are diagnosed with [REDACTED]. difficulty, or who have a history of trauma and/or post-traumatic stress disorder receive appropriate treatment and services to address the problem. Review of R #66's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed an admission date of [DATE]. R #66 had [DIAGNOSES REDACTED]. R #66 was coded as severely cognitively impaired and noted to have had one to three days of physical behavioral symptoms and other behavioral symptoms during the seven-day assessment period. The resident was administered antipsychotic, antianxiety, and antidepressant medications for seven days during the assessment period and received no psychological therapy. Review of R #66's Quarterly MDS dated [DATE] revealed during this assessment period, the resident was coded as moderately cognitively impaired; and had physical behavioral symptoms for one to three days; other behavioral symptoms one to three days; put others at significant risk for physical injury; significantly intrudes on the privacy or activity of others; significantly disrupts care or living environment. R #66 had no impairment of upper or lower extremities and utilized a wheelchair for locomotion on the unit which required the supervision of one staff. The resident was administered antipsychotic, antianxiety, and antidepressant medications for seven days during the assessment period and received one day of psychological therapy for at least 15 minutes within the last seven days. Review of R #66's Clinical [DIAGNOSES REDACTED].#66 had [DIAGNOSES REDACTED]. Review of R #66's Preadmission Screening and Resident Review (PASRR) Level II documentation (undated) (page six of seven) noted his pertinent medical conditions: Current medical admission due to volume depletion, severe dehydration and left focal motor [MEDICAL CONDITION]. Medical conditions include [MEDICAL CONDITION] due to either diverticulitis or bowel obstruction in (YEAR). The document noted: (R #66) has always lived at home with his mother .he has recently been aggressive toward her and other family members when he is frustrated .A psychiatric assessment from 11/15/15 reported an increase in aggressive behaviors at that time .assessment also noted recent trouble with authority, verbal abuse, swearing and decreased attention span. Review of R #66's physician's orders [REDACTED]. There were no orders for behavior monitoring/documenting, or for monitoring/documenting side effects of the medications. Review of R #66's clinical record revealed he had the following documented behavioral incidents: 2/5/18 - (Interdisciplinary (IDT) Progress Notes) - resident alert poor decision making - will grab others, talks loud and gets disruptive - can ambulate unsteady . 3/4/18 - (Situation, Background, Assess, Review (SBAR) form) - grabbing others. Resident wandering hall, grabbing others - stealing chips. Resident up from wheelchair wandering halls grabbing at other resident, grabbed resident's arm and took her chips. residents separated, educated on not grabbing and taking others stuff. 3/8/18 - (Patients at Risk (PAR) Review) - R #66 was wandering down the hall and saw another resident with snacks. R #66 grabbed the other resident's snacks and he also grabbed the female resident's arm. There was no injury. The residents were separated. According to the form, the resident's care plan was not revised or updated. 3/15/18 - (Behavior Assessment) - resident gets agitated with roommates and he mimics their behavior. As an intervention social services and activities will assess resident for likes and dislikes to create activities that he will enjoy doing and to keep him occupied. 3/20/18 - (SBAR) - discolored small digit on left hand. Resident reportedly unable to relay information about how injury occurred. 3/22/18 - (Behavior Assessment) - R #66 was in an altercation with roommate and he suffered from an injury of a broken finger. R #66 has been educated about keeping his hands to himself and not throwing things at his roommates. R #66's room has also been changed for safety reasons. 3/27/18 - (IDT Progress Note) - R #66 is awakened easily and moves thru out hall with his feet while he's in wc (wheelchair). He approaches women residents when they don't want him to. Easily diverted to something else. 3/31/18 - (IDT Progress Note) - R #66 grabbed another resident by shirt, pulled resident and w/c over without provocation. Notified family and MD, new order for UA C&S d/t increased behaviors, anxious and uncooperative. 4/3/18 - (IDT Progress Note) - Pt. (patient) out of room a while before breakfast. Up and down the hall with people saying, Don't touch me. I gave his meds which distracted somewhat. He returned to his bedroom and ate well. In and out of bed at will. 4/23/18 - (SBAR) - Resident came down B Hall to A Hall in front and started choking another resident. Resident approached another resident and put right hand around her neck and resident began to scream until we were able to stop him. The resident's primary care physician (PCP) was notified on 4/23/18. There was no documentation to indicate the resident's psychiatrist was notified of the incident. 5/1/18 - (PAR Review) - R #66 choked another resident while she was sitting at the nurse's station. Residents had to be separated by staff. Resident has a history of grabbing at staff/residents. He is not easily redirected. Resident also has a history of altercations with other residents. According to the document R #66's care plan was revised and updated. 5/14/18 - (SBAR) - altercation. Resident entered another resident's room to talk to resident in middle bed. The other resident accidently scratched him when trying to remove him from room. Then R #66 yelled Please don't hurt me. Scrape to right side of cheek/face with two welts, 2 centimeters (cm) long. Scratch to right side cheek - no treatment necessary - clean leave open to air. The resident's primary care physician (PCP) was notified on 5/14/18. There was no documentation to indicate the resident's psychiatrist was notified of the incident. 5/16/18 - (IDT Progress Note) - resident alert, took meds, scratch to right side cheek dry, needs frequent redirecting, monitoring for touching others and entering other resident rooms. 6/20/18 - (IDT Progress Note) - R #66 walking in hall on B Hall without wheelchair. Nurse was redirecting resident to get his wheelchair, and R #66 lunged at nurse stating, I want pretty girl. Maintenance Staff (MS) BB helped redirect patient because nurse was unsuccessful. Resident was verbally redirected. 6/23/18 - (SBAR) - R #66 was pushed to the floor- wanders into other residents' rooms uninvited. Another resident pushed resident against a table that caused an indention (temporary) and abrasion without broken skin to the upper mid back. No broken skin - redness with indentation on mid upper back. Monitored throughout the day, no changes in condition or c/o pain, ambulatory and frequently reminded resident is not to go into the rooms of others without being invited. The resident's primary care physician (PCP) was notified on 6/23/18. There was no documentation to indicate the resident's psychiatrist was notified of the incident. 6/25/18 - (IDT Progress Note)_ - Writer found resident in another resident's room with female resident, attempting to take sock off of female resident. Residents separated and writer educated resident on personal space and not touching others without permission. Resident only responded I know I know. Female resident stated that R #66 thumped her helmet causing it to fall off backwards. R #66 removed from room, asked if he would like to attend activity. 6/25/18 - (Behavior Assessment) - resident was noted grabbing and touching another resident. Resident was redirected by staff. Call placed to doctor about resident's increased intrusiveness to others. Awaiting return call. Review of a facility reportable incident dated 3/26/18 revealed an investigation was conducted regarding R #66 sustaining a broken finger discovered on 3/20/18. According to the investigation, R #66 and his roommate had a verbal and physical altercation that involved R #66 throwing water on his roommate, and the roommate grabbing R #66's hand which caused a fracture to his left fifth digit. The report noted responsible parties have been notified of findings and care plans have been updated. Review of R #66's Psychiatric Medication Evaluation noted R #66 was seen by his psychiatrist three times since (MONTH) (YEAR), and the following was noted: 9/21/17 - Presenting Problems and interval history: Remains low functioning and impulsive. Touches others to communicate and they quickly get hostile with him. Overall more alert and responsive. Description of session: Seems calm and redirectable but involved in conflicts because of poor social skill. Recommendations for PCP (primary care physician)/Facility Staff: Doubt med (medication) changes will help. Cont. [MEDICATION NAME] for depression, low dose klonopin for impulsivity, [MEDICATION NAME] helps sleep/delusions. 2/18/18 - Presenting Problems and interval history: Remains regressed, intrusive, impulsive and unsafe. Fall risk, aggravates peers to point of getting hurt and in general population - grabs females and goes in their rooms without understanding. Mental status exam: Can't control himself well, resists redirection at times. Description of session: Can't understand his problem even when reviewed. Laughs with MD (doctor) about his behaviors. Recommendations for PCP (primary care physician)/Facility Staff: Discussed with numerous staff, his risks with intrusiveness impulsivity and unsteady gait make interventions needed now for safety. Increase klonopin to .5 mg t.i.d, add [MEDICATION NAME] 50 mg q evening (pm). 5/4/18 - Presenting Problems and interval history: Slightly calmer on [MEDICATION NAME] over [MEDICATION NAME] with klonopin. Can be redirected a little less intrusive. Still a problem in the general population unit. Impulsive, inflexible, not delusional. Recommendations for PCP (primary care physician)/Facility Staff: Some calming and increase safety. Will see if trends in intrusive impulsivity worsen and could increase [MEDICATION NAME]. For now, no changes, no new (side effects) Review of R #66's behavior care plan initiated on 4/24/17 revealed: Problem (Onset date: 4/24/17; Effective date: 2/15/18): resident has a [DIAGNOSES REDACTED]. He grabs at staff and peers. He doesn't like things out of place and he doesn't like doctors, history of hitting and kicking and history of cursing and saying shut up, staff reports he gets anxious when his surroundings are loud. Pulls on other residents to get their attention. Resident started punching another resident and fell to the floor, (R #66) has a history of grabbing a staff members clothes and face swinging hands and hit staff member in the face; goes into other residents' rooms uninvited; touches other residents and staff inappropriately. 3/7/18 - sister-in-law states he hasn't been told no and she will try to come in today to talk with him; 3/15/18 - (R #66) acts out when his roommates provoke him; 3/20/18 - Resident is not to have a water cup at bedside (due to) d/t throwing it at peers; 6/25/18 - picking at another resident by touching her on the head, pulling socks off, touching her feet, he went into another resident's room. Goal: Resident will not injure self or others as a result of behavior during the review period (8/31/18); 3/15/18 - To observe residents and to ensure they are following safety guidelines; 3/20/18 - Resident will not injure others as a result of behavior Interventions: 4/24/17 - notify MD for any new behaviors or exacerbation of behaviors/pharmacy consult for review of meds/talk with resident in a calm and reassuring voice; direct resident's attention away from cause of behavior if possible/assess for possible physical causes of behavior/assess for situations/occurrences that cause inappropriate behavior. 7/18/17 - Observe for behaviors and concerns and attempt diversions to alter praise for involvement and socialization and his attempts to console others; 9/14/17 - redirect resident at pulling on others; 1/14/18 - involve in group events escort from the group when verbal and physical behaviors disrupt the group and offer room activities 1:1 offer music, w/c rides outside, variety of settings; 1/26/18 - resident goes to DON office to talk and distress when behaviors occur; 3/15/18 - assess residents for likes and dislikes for different activities to keep resident occupied; 3/20/18 - water cup removed - resident transferred to another room; 6/25/18 - consult care now services/reassess behavior/assign to a staff member if he is awake in wheelchair. R #66's behavioral care plan was not revised/updated after R #66's psychiatrist recommended facility staff develop and \implement interventions to address the resident's intrusive/impulsive behavior on 2/16/18. The behavioral care plan was not revised/updated after R #66 pulled over a resident in their wheelchair on 3/31/18. It was not updated/revised after R #66 choked another resident on 4/23/18, The behavioral care plan was not updated/revised after R #66 sustained minor injury to the face after entering another resident's room on 5/14/18; and the behavioral care plan was not updated after wandering into another resident's room and sustaining minor injury to his back on 6/23/18. Review of R #66's [MEDICAL CONDITION] drug usage care plan dated 4/24/17 revealed: Problem: Takes [MEDICAL CONDITION] medication; takes antidepressant, antianxiety, and antipsychotics. Has [DIAGNOSES REDACTED]. Goal: Resident will not develop any significant side effects related to [MEDICAL CONDITION] drug use during the review period (8/31/18). Interventions: 4/24/17 - Observe and report any decline in functional status; 4/24/17 - observe and report signs and symptoms of postural [MEDICAL CONDITION] (dizziness, [MEDICAL CONDITION] upon standing, [MEDICAL CONDITION], falls); 4/24/17 - observe for involuntary movement disorders; 4/24/17 - consult with pharmacy or doctor for medication review; 4/24/17 - monitor and document frequency and behaviors patient is exhibiting; 4/24/17 - observe for increased constipation, [MEDICAL CONDITION], dehydration, or dry mouth; 4/24/17 - give medication as ordered; 4/24/17 - monitor labs as ordered and report to doctor as needed. Review of R #66's [MEDICAL CONDITION] drug usage care plan revealed it was not updated/revised after it was initiated on 4/24/17. Review of R #66's Behavior Monitoring Record for (MONTH) & (MONTH) (YEAR) revealed R #66's monitored behaviors did not include wandering, and staff documented the resident exhibited no target behaviors, as follows: Depressed/Withdrawn - 0 Socially Inappropriate Behavior - 0 Striking out at staff/other residents - 0 Yelling/Screaming - 0 Disruptive behavior - 0 Crying - 0 Review of R #66's Behavior Monitoring Record for (MONTH) (YEAR) revealed there was no documentation for any target behaviors between 6/1/18 through 6/28/18. The forms were blank, and there was no documentation to indicate if any target behaviors occurred. Review of R #66's IDT Discharge Planning Notes completed by Social Services revealed the following: 1/30/18 - Social Services is trying to find placement for resident for his d/t safety issues. 1/31/18 - Today Social Services spoke with family and explained that R #66 would not be safe with the doors to the men's unit being open. It was also explained that there was a concern for his safety as well as the other residents. Review of the resident's Elopement Risk assessment dated [DATE] noted the resident was a low elopement risk. The assessment did not assess wandering, and there was not a wandering assessment located in the resident's clinical record. 1. Observation during the initial pool (B Unit) on 6/25/18 at 11:30 a.m. revealed R #73 was heard repeatedly yelling Stop, (R #66)! R #66 was observed to hit, push and thump R #73's helmet. R #66 would not stop as requested, and R #73 could not prevent him from moving her helmet to the back of her head. Nursing staff was alerted to the altercation (by Surveyor intervention), and upon arrival, Licensed Practical Nurse (LPN) AA redirected R #66 and attempted to separate him from R #73 by backing up his wheelchair. R #66 stood from the wheelchair and grabbed R #73's left foot, removed her sock and squeezed the toes on R #73's left foot. LPN AA verbally and physically prompted R #66 to sit in his wheelchair, and after several prompts R #66 complied. Interview on 6/25/18 at 11:35 a.m. in the hallway of B Unit, LPN AA stated R #66 exhibits this type of behavior daily. The nurse stated staff are often separating him from altercations with other residents, and from going into other residents' rooms uninvited. The nurse stated R #66's behavior was difficult to manage, and the nurse was unsure of the interventions listed in his care plan. 2. During a group interview on 6/26/18 at 11:34 a.m. in the facility's activity room, R #28 stated approximately one month ago, R #66 grabbed a chunk of her hair and started pulling her down to the floor and staff separated them. R #28 stated on another occasion, R #66 came by and started reaching for her hair again she grabbed his finger and pushed it back. R #28 stated R #66 has a history of touching R #73 and other female residents. R #28 has heard R #73 yell (R #66), No! Stop it! Review of R #28's Quarterly MDS dated [DATE] revealed an admission date of [DATE]. R #28 scored 12/15 on the Brief Interview for Mental Status (BIMS) score, indicating moderate impairment. During the assessment period, R #28 was coded to have hallucinations and delusions. The resident was assessed to have no other behavioral symptoms. Review of R #28's clinical record revealed an SBAR dated 4/9/18 which documented (R #66) approached R #28 and fanned his hand in her face. She caught his hand and started pulling his fingers back. R #28 started yelling get away from me when R #66 approached her and started waving his hand in her face. She catches hand and starts pulling fingers back. 3. Interview in the Director of Nursing's (DON's) office on 6/28/18 at 8:46 a.m. with the facility's Director of Nursing (DON) revealed that the 3/15/18 intervention noted in the behavioral care plan should have been done by the Activities Director and then added to the resident's care plan. The DON confirmed there was not a record this intervention was completed by the Activities Director. The DON stated the Activities Director was currently on vacation. The DON said R #66's behavior has been going on for a couple of months, and the interventions to address his behavior of wandering into others' rooms was to go up to him and calmly tell him he's not allowed to be in that room, and then redirect him with food/drink/different place. The DON stated, when in the hallway R #66 is allowed to roam - he goes up and down halls and talk to everybody. The DON has seen him frequent R #73's room. The DON said R #66's care plan did not address redirection before the resident went into other's rooms. She also confirmed R #66 has been hurt by other residents after going into their rooms. When asked about several of R #66's behavioral incidents, the DON stated, if there was not an SBAR for an incident, I probably don't know about it. This surveyor went over each incident (3/31/18 thru 6/23/18) with the DON regarding the implementation of strategies to manage the resident's behaviors & the DON said, Honestly, other than separating the residents and keeping them occupied, there was no other intervention put in place to address his behavior. Only immediate intervention and redirection. When asked about R #66 seeing the psychiatrist, the DON confirmed he was last seen on 5/4/18, and he was usually seen every three months unless something occurs. He is scheduled to be seen again, in (MONTH) (YEAR). The DON said in talking with the psychiatrist about him, he doesn't feel medication all the time is the answer. The psychiatrist felt redirection and keeping R #66 occupied worked better for him. When asked about the behavior monitoring record, the DON said staff should be documenting the resident's behaviors on the behavior monitoring record and that information was then used to update/revise the care plan and inform the doctor(s) about his behaviors. She also confirmed the resident's behavior of wandering should be tracked and was not. Telephone interview on 6/28/18 at 9:32 a.m. in the DON's office with R #66's psychiatrist revealed R #66 had a history of [REDACTED]. The psychiatrist said it was best for R #66 to either reside in a facility where there was little stimulation, or in a facility that had a secure unit. The psychiatrist said because the resident did not reside in either of those settings, he had the potential to engage in fights with other residents. When asked about some of the resident's recent behavioral incidents (sustaining a broken finger, choking another resident), the psychiatrist stated he did not recall every incident he received a call on regarding R #66. Continued interview revealed R #66 was seen by the psychiatrist at least every three months, and he had an expectation to be called when a serious incident occurred. The psychiatrist said R #66 could be put on the list to be seen more often, or as needed. He further stated he expected staff to develop a plan of care that was consistent with care, that maintained a structured environment for the resident, and that provided as little distraction and stimulus, as possible. R #66's psychiatrist said by facility staff allowing R #66 to self-propel on all three units without supervision could be problematic and lead to behavioral incidents. Follow-up interview with the DON on 6/28/18 at 4:53 p.m. in the MDS Coordinator's office confirmed the facility had no assessment that addressed resident wandering. The facility only completed an elopement risk assessment upon admission and annually.