Every finding on record at Prince George Healthcare Center

Based on review of the facility policy, observations, and interviews, the facility failed to date, label, and/or cover food products stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 125 of 137 residents who consumed food prepared from the facility's kitchen.Findings include:Review of the facility's policy titled, Nutrition Policies and Procedures, dated 08/01/20, in the section titled Food Safety in Receiving and Storage stated that, Refrigerated . foods are property covered, labeled, dated with a use-by date and refrigerated immediately. [NAME] them clearly to indicate the date which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. During a tour of the kitchen on 06/28/26 at 10:20 AM, observation of the main walk-in refrigerator revealed the following: An open cardboard box contained 78 tomatoes, and 10 tomatoes had visible black spots. An open half gallon of milk (half full) had no date label.A head of cabbage on the middle shelf was without plastic wrapping or date labels. An open cardboard box of cheese slices individually wrapped in plastic had no date labels on the cardboard box or the plastic wrap. There were three stacks, and each contained 15 slices. A bag of hard-boiled peeled eggs in plastic wrapping (total of 24 eggs) was not dated. An open cardboard box of turkey slices in individually wrapped plastic had no date labels on the cardboard box or the plastic wrap. There were five packets, and each contained six slices. Observation of the main walk-in freezer included: An open, undated box contained an open, undated bag of 75 pieces of frozen chicken cutlets.An open, undated box contained an open, undated bag of 56 frozen corn dogs.An open, undated box contained an open, undated bag of 67 frozen chicken nuggets. An open, undated box contained an open, undated bag of 47 frozen hot dogs. The hot dogs were covered with ice crystals.An open, undated box contained an open, undated bag of 24 loose pieces of frozen garlic toast. The toast was covered with ice crystals.An open, undated box contained an open, undated bag of 34 pieces of frozen fish.A five-pound cylinder of frozen ground beef had a use by date of 05/31/26. During an interview on 06/29/26 at 09:15 AM, the Dietary Manger (DM) confirmed the above observations and stated that all products should be in closed packaging and dated by staff when taken out of the main refrigerator. The DM confirmed that all products should be used before the date expires. The DM also stated that there was no schedule for food to be checked for dates or expiration.

Based on record review, staff interview, and facility policy review, the facility failed to ensure the resident or the resident's authorized representative received timely written notification of Medicare non-coverage through the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) or the Notice of Medicare Non-Coverage (NOMNC) for two (Residents (R) 77 and R151) of three residents reviewed for beneficiary notification, out of a total sample of 30 residents. This deficient practice had the potential for the residents and/or representative not to have the required information to make an informed decision regarding their care and services. Findings include:Review of the facility's SNF BENEFICIARY NOTICES OF MEDICARE NON-COVERAGE DETERMINATION, policy, revised 04/2018, states: Residents or persons acting on their behalf are to be advised in writing at least two days before Medicare-covered services end. If the representative cannot be personally notified, the facility must: document the telephone contact, complete at least two documented telephone attempts if unable to reach the representative,mail the written notice, and maintain documentation of these actions. The policy also requires the beneficiary or authorized representative to sign the SNFABN or NOMNC, or, if refusing to sign, the refusal must be documented and witnessed. 1. Review of R77's SNFABN form provided by the facility revealed the Medicare Part A skilled services start date was 01/03/26. The form was signed and dated by Social Services (SS) 1 on 01/02/26. The Signature of Patient or Authorized Representative reflected SSA notified RP and witnessed by SS1 and SS2. The form did not contain the signature of the resident or authorized representative. There was no documentation identifying the individual who was notified, documenting telephone contact, documenting multiple contact attempts, or indicating the written notice had been mailed to the authorized representative. R77 remained at the facility. 2. Review of R151's NOMNC provided by the facility revealed Medicare-covered skilled services were scheduled to end on 04/24/26. The form was signed by Social Services (SS) 1 on 04/22/26; however, the resident's or authorized representative's signature was absent. Instead, the signature line reflected SSA notified RP, witnessed by SS1 and SS2. There was no documentation identifying the responsible party contacted, documenting telephone notification, documenting multiple contact attempts, or showing the notice had been mailed prior to discharge. During an interview on 06/30/26 at 11:30 AM, SS1 stated residents or their representatives are notified when Medicare-covered skilled or therapy services were ending. SS1 stated both residents were cognitively impaired and attempts were made to notify the responsible parties by telephone. However, SS1 was unable to identify who had been contacted, could not produce documentation of the telephone attempts or successful notification, acknowledged notices were not mailed to the responsible parties, and confirmed no progress notes were entered documenting notification attempts or receipt of the notice. During an interview on 06/30/26 at 12:49 PM SS2, stated residents or their authorized representatives must receive the NOMNC at least 48 hours before Medicare coverage ends. SS2 further stated the forms should contain the signature of the resident or authorized representative and the medical record should include documentation of telephone contact attempts and when the notice was mailed if telephone notification was unsuccessful.

Based on review of facility policy, record reviews, observation and interviews, the facility failed to ensure one resident (Resident (R)74) of one reviewed for contractures had a splint in place per physician's orders out of a total sample of 30 residents. This had the potential for the resident's contracture to decline. Findings include: Review of the facility's policy titled, Joint Mobility/ Range of Motion Program and Splinting with a revision date of 10/25/24 indicated, Patients/ residents will be assessed for joint mobility limitation upon admission, re-admission, quarterly, annually, and with significant changes through the comprehensive nursing assessment. A restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated or upon discharge from skilled therapy. Orthotic, assistive, or prosthetic devices will be provided if indicated. Review of R74's Face Sheet located under the Resident tab of the electronic medical record (EMR) indicated the resident was admitted on [DATE] with a diagnosis of contracture of muscle. Review of R74's Occupational Therapy (OT) Discharge Summary provided by the facility with dates of service 12/08/25 through 02/04/26 indicated resident will demonstrate resident specific optimal positioning of right hand in extension, maintain and tolerate with use of orthotic for five hours to aid with joint/skin protection and pain management/prevention for increase in quality of life. Review of R74's Care plan located under the RAI [Resident Assessment Instrument] tab of the EMR revealed the resident requires splint/ brace due to contracture to right hand and to monitor splinted sites for hygiene and skin breakdown, start date 02/10/26. Review of R74's Active Orders located in the Resident tab of the EMR revealed the nurse was to verify placement of the fabricated palm roll splint to the right hand with a start date of 02/10/26. Review of R74's Therapy Screening Form provided by the facility with an observation date of 03/05/26 indicated R74 was currently on Restorative Nurse Program (RNP) for Passive Range of Motion (PROM) of right hand and donning of fabricated palm roll splint to right hand. Review of R74's Therapy Screening Form provided by the facility with an observation date of 06/29/26 indicated R74 had joint limitations/contractures and the resident was warranting Occupational Therapy (OT) assessment in order to gain updated function of upper extremity and continued appropriateness of previously implemented devices. During an observation on 06/28/26 at 2:26 PM, R74 was lying in bed on his back and had a right-hand contracture with no device present. During an interview on 06/29/26 4:34 PM, Certified Nurse Assistant (CNA)6 was at R74's bedside and confirmed the resident's right hand was contracted with no device present. She confirmed the resident did not have a device. During an interview on 06/29/2026 4:38 PM, Assistant Director of Nursing (ADON) was at R74's bedside and she confirmed the resident's right hand was contracted with no device present. She confirmed the resident did not have a device. The ADON stated, therapy discontinued it to see how he would do without it. During an interview on 06/29/26 at 5:04 PM, the Director of Nursing (DON) confirmed the resident did not have a device and therapy discontinued it. The DON stated, It was a decision made by the therapy department to discontinue the use of the splint. During an interview on 06/30/26 at 11:54 PM, the Interim Director of Rehabilitation (IDOR), revealed R74 was discharged from therapy in February of this year, and they had a splint for him and handed the resident off to the restorative team. She stated, We picked him back up yesterday and screened him and will evaluate to treat. During an interview on 06/30/26 at 12:02 PM, the Restorative Certified Nurse Aide (RNCA) stated, he has a rolled splint that we put on his hand. She revealed she couldn't find it and she went to OT and R74 needed a new one a few weeks ago and she saw it on the resident today.

Based on observation, interviews and record review, the facility failed to ensure an indwelling urinary catheter collection bag was maintained in a privacy bag for one of one residents (Resident (R)74) reviewed for catheters out of a total sample of 30 residents. The failed practice had the potential to effect the resident's dignity. Findings include: Review of R74's Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with a diagnosis of neuromuscular dysfunction of bladder. Review of R74's Care Plan located under the RAI [Resident Assessment Instrument] tab of the EMR revealed the resident required a suprapubic catheter related to neurogenic bladder, penile complications and to store collection bag inside a protective, dignity pouch, start date 04/10/26. Review of R74's Active Orders located under the Resident tab of the EMR indicated indwelling surgical post catheter 20 french (fr.) 30 cubic centimeter (cc) for neurogenic bladder, start date 06/15/26; privacy bag in place, start date 10/22/25. Review of R74's Minimum Data Set (MDS) located under the RAI tab of the EMR with an Assessment Reference Date (ARD) of 06/23/26 revealed R74 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact and the resident had an indwelling catheter. During an observation on 06/28/26 at 11:56 AM, R74 had an indwelling catheter not in a privacy bag. Catheter was on non-movable part of the bed with no kinks and draining yellow urine, hanging on the side of the bed facing the door. The catheter bag could be seen from the hallway. During an observation on 06/28/26 at 2:30 PM, R74 had an indwelling catheter not in a privacy bag. Catheter was on non-movable part of the bed with no kinks and draining yellow urine, hanging on the side of the bed facing the door. The catheter bag could be seen from the hallway. During an interview on 06/28/26 at 2:41 PM, Certified Nurse Assistant (CNA)2 confirmed R74's indwelling catheter was not in a privacy bag and should be. CNA indicated it was needed to respect their privacy. During an interview on 06/28/26 at 2:43 PM, Assistant Director of Nursing (ADON) confirmed R74's indwelling catheter should be in privacy bag for dignity reasons. ADON stated the resident had a urology appointment on Wednesday and must not have come back with it. During an interview on 06/29/2026 on 5:04 PM, Director of Nursing (DON) stated, The nurse should've seen it and changed it when the resident returned from his urology appointment last Wednesday. The facility did not have a policy related to privacy bags for catheters.

Based on record review, observation, and staff interview, the facility failed to ensure the comprehensive assessment accurately reflected a contracture for one (Resident (R) 74) of one residents reviewed for contractures in the sample of 30 residents. This failure had the potential to lead to the decline of the resident's contracture. (Cross Reference F688) Findings include:Review of R74's Face Sheet located under the Resident tab of the electronic medical record (EMR) indicated the resident was admitted on [DATE] with a diagnosis of contracture of muscle. Review of R74's Active Orders located in the EMR under the Resident tab revealed the nurse was to verify placement of a fabricated palm roll splint to the right hand with a start date of 02/10/26. Review of R74's Care plan located under the RAI [Resident Assessment Instrument] tab of the EMR revealed the resident requires splint/brace due to contracture to right hand and to monitor splinted sites for hygiene and skin breakdown, start date 02/10/26 Review of R74's quarterly Minimum Data Set (MDS) located under the RAI tab of the EMR with an Assessment Reference Date (ARD) of 06/23/26 revealed no functional limitation in range of motion with upper extremities. During an interview on 06/29/26 at 4:38 PM, Assistant Director of Nursing (ADON) at R74's bedside she confirmed the resident's right hand was contracted. During an interview on 06/30/26 11:17 AM, Minimum Data Set Coordination (MDSC) confirmed R74's MDS was incorrectly coded. She confirmed the resident had a right-hand contracture and the MDS should reflect the residents hand contracture. MDSC stated, accuracy is most important especially for insurance and doing the care plan. It drives his care. The facility did not have a policy related to MDSs.

Based on review of the facility policy, observations and interviews, the facility failed to ensure foods, prepared and frozen, were stored properly. The facility further failed to ensure the dry storage room was kept clean and free from spillage and debris in one of one main kitchen. Findings include: Review of the facility policy titled, Food Safety in Receiving and Storage, with a complete revision date of 06/20/23 states Policy: Food will be received and stored by methods to minimize contamination and bacterial growth. Under General Food Storage Guidelines it states, 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. Under Refrigerated Storage Guidelines it states, 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage. An observation on 06/08/25 at 10:20 AM of the main kitchen revealed: Walk in cooler contained: -Seven salads, previously made, and placed in carry-out containers with no date and no expiration date. Walk in freezer contained: -Two bags of breaded chicken filets opened and repackaged in a plastic bag with no open date and no expiration date. -One bag of sliced garlic bread, repackaged with no label, no open date. -One partially used bag of chocolate chip cookie dough, open with no dates. -One large box of fish filets, opened and not sealed, with no dates. -One bag of chicken parts, repackaged with no label and no open nor expiration date. -A plastic bag with 2 pieces of fish, partially used with no dates. -One bag of Zucchini partially used, with no open date and no expiration date. -A large bag of mixed veggies partially used with no dates. -A large cardboard box of sausage, opened, partially used, and not resealed, with no open date. The sausage was dried out and dark in color. Outside Freezer: -One bag of frozen cookies opened, partially used, and contained no dates. During an interview with the [NAME] on 06/08/25 at 10:40 AM, she confirmed the findings and removed the salads from the cooler, and the unlabeled items from the freezers. Review of the Cleaning Schedule, dated 06/01/25-06/07/25 revealed the Storeroom Clean and Date, that was signed off by dietary staff as cleaned. An observation on 06/08/25 at 10:45 AM of the dry storage room, revealed dirt, food, and debris on the floor. There was spillage on the floor along with debris under the bottom shelf that was covered by plastic containers. The plastic containers were outlined along the outer edges by the dirt and debris. On one shelf, was a crushed, single serving of pancake syrup that was dry on the shelf with a cardboard box stuck to it. During the observation of the dry storage room with the [NAME] on 06/08/25, she confirmed the findings and stated that the dry storage room is cleaned every other day and mopped daily. On 06/10/25 at an unspecified time, during a conversation with the Certified Dietary Manager (CDM), she stated the staff clean the dry storage regularly and provided the cleaning schedule. She stated that the dry storage room was cleaned on 06/07/25 and was signed off by staff.

Based on review of the facility policy, observations and interviews, the facility failed to ensure the refuse dumpsters were not overfilled and closed with tight fitting lids for 2 of 2 dumpsters observed outside of the kitchen, in a newly paved area. Findings include: Review of the facility policy titled, Waste Disposal with a revision date of 06/20/23, states, Waste will be disposed of in a manner to prevent transmission of disease, nuisance or breeding place for insects and feeding places for rodents and other mammals. Procedures: 1. Waste is not disposed of by garbage disposal. It is kept in leak proof non-absorbent containers with close fitting lids. 2. Dispose of waste in closed trash bags. 3. Cover waste containers in transport to dumpsters. 4. Remove trash frequently enough to prevent overflow. 5. Always cover waste containers and close dumpsters. 6. Keep waste containers clean, odor free and without cracks. 7. Keep area around refuse dumpsters clean, odor and rodent free. An observation on 06/08/25 at 10:50 AM of the outside dumpsters revealed, 2 large dumpsters overfilled, and the lids were unclosed due to the overflow of trash and refuse. During an interview with the [NAME] on 06/08/25 at 10:50 AM, she confirmed that the 2 dumpsters were overfilled and the lids were not closed. During an interview with the Certified Dietary Manager (CDM) on 06/09/25 at approximately 10:15 AM, she stated that the dumpsters normally do not get that full and if they have an excess of trash then it is carried to another dumpster else where on the property. She also confirmed that the lids should be closed at all times.

Based on review of the facility policy, observations, record reviews, interviews and the manufacturer's FDA (Food & Drug Administration) approved package insert, the facility failed to ensure that a resident (R)106, was free of an unnecessary psychotropic drug for 1 of 5 residents reviewed for unnecessary medications. Findings include: A review of the facility's policy titled, PHARMACY SERVICES POLICIES AND PROCEDURES: SECTION 6- MEDICATION MANAGEMENT, SUBJECT: 6.8 UNNECESSARY DRUGS revised 4/17/2024 revealed 3. Unnecessary drugs are defined as any drug when used: .D. Without adequate indication for its use. A review of the FDA approved manufacturer package insert guidelines for the use of for Seroquel (quetiapine) revised October 2013 revealed, Indications and Usage: Seroquel is an atypical antipsychotic indicated for the treatment of: Schizophrenia, Bipolar I disorder manic episodes, and Bipolar disorder, depressive episodes. R106 was originally admitted to the facility on [DATE] from a local hospital with an order for Quetiapine 100 mg (milligram) + 50 mg hs (bedtime) and was readmitted to the facility on [DATE] after a shoulder aspiration with diagnoses including, but not limited to vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the Electronic Medical Record (EMR) Quarterly Minimum Data Set (MDS) for R106 with an Assessment Reference Date (ARD) of 03/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicates moderate cognitive impairment and that R106 had received antipsychotic medications on a routine basis with the last Gradual Dose Reduction (GDR) documented by the physician on 03/26/2024, as being clinically contraindicated. On 06/9/25 at approximately 11:00 AM, a review of the June 2025 EMR physician orders for R106 revealed: -Seroquel 100 mg with a 50 mg tablet (total 150 mg) HS for vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety ordered 5/15/24 and discontinued 1/16/25. -Seroquel 100 mg administer with a 25 mg tablet (125 mg total) HS for vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety ordered 1/16/25 as open ended (until discontinued). -Trazodone 50 mg HS - insomnia ordered 5/15/24 and discontinued 2/24/25. On 06/09/25 at approximately 2:00 PM, a review of the medication administration records (MARS) since 05/15/24 revealed that all doses for Seroquel and Trazodone had been administered as prescribed. On 06/09/25 at approximately 4:45 PM, review of a pharmacist GDR recommendation to the attending physician/prescriber, dated 03/19/24, revealed that R106 was receiving Quetiapine 150 mg at bedtime and the prescriber on 03/26/24 had indicated MEDICATION CONTINUATION: Psychotropic medication is controlling and improving target symptoms. Continue until next review and further review of a GDR recommendation, dated 2/20/25, whereby the physician accepted a Trazodone GDR recommendation and wrote a new order Trazodone 25 mg q (every) HS x 1 wk (week), then D/C (discontinue). On 06/10/25 at approximately 11:00 AM, further review of the EMR revealed that on 09/16/24, a physician progress note indicated recurrent major depressive disorder in remission. did not tolerate GDR of Seroquel Spring 2023. Psych is following and on 5/28/25 Major Depression/Mood Disorder: Chronic, stable moods on Seroquel GDR done [DATE] w/o (without) apparent worsening. On traz (Trazodone) prev (previously) by dc' d (discontinued) Mar (March) 2025. During an interview with the Administrator and Director of Nursing (DON) on 06/10/25 at approximately 11:45 AM, the Administrator stated in response to being asked How do you ensure that the attending physician's supervise the medical care of residents with dementia and their use of antipsychotic medications? The Administrator stated, This is overseen by the Medical Director. On 06/10/25 at approximately 12:30 PM, the Administrator stated that the Medical Director cannot be reached because she is out of the country and provided a telephone number for the Physician Assistant. On 06/10/25 at approximately 12:35 PM and 12:43 PM, the Surveyor tried to contact the Physician's Assistant, but the phone was busy and mailbox was full, being unable to leave a message. These calls were not returned. On 06/10/25 at approximately 2:30 PM, the DON provided documentation that the spouse of R106 had consented to a request for mental health services on 04/23/23 and that R106 had refused psych services on 04/26/23 with a physician signature dated 04/27/23 and stated to her knowledge the resident had never received psychiatric services.

Based on review of the facility policy, observations, and interviews, the facility failed to assure that medications were properly stored according to manufacturer labeling in 1 of 3 treatment carts. Findings include: Review of the facility's Policy and Procedures entitled GENERAL GUIDELINES FOR STORAGE OF MEDICATION AND BIOLOGICALS revised 4/17/2024 states 1. Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . On 06/09/25 at approximately 11:30 AM, inspection of the Indigo treatment cart revealed: one opened TheraHoney Gel 1.5 ounce tube dated 06/02/25 by Medline labeled Sterile in unopened, undamaged package. Single Use Only and one opened Plain Packing Strip 1/4 inch x 5 yards by Curad labeled Sterile in unopened undamaged package. Single Use Only. On 06/09/25 at approximately 11:35 AM, these findings were reviewed and verified by Licensed Practical Nurse (LPN)1, who stated she was unfamiliar with the manufacturer labeling. On 06/10/25 at approximately 11:50 AM, the Director of Nursing (DON) stated she was aware of this finding, but was unaware of the manufacturing labeling related to these products being single use only.

Based on observations, interviews, and facility policy, the facility failed to follow the facility infection control protocol to hand sanitize prior to entering resident rooms to provide medication administration in order to prevent cross-contamination for residents on Enhanced Barrier Precautions. This failure affected five (5) of five (5) sampled residents (Residents #3, 46, 91, 96 and 337). The findings include: Review of a facility policy titled Infection Prevention and Control Policies and Procedures revised date, 5/15/23, documented the following: SUBJECT: Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (Continued) PROCEDURES: Enhanced Barrier Precautions (EBP) The facility will provide access to hand hygiene supplies prior to entering and exiting the resident's room. 5. Fundamentals of Precautions A. Hand Hygiene/Hand washing and Gloving 1) Hand Hygiene/Hand washing is the single most important measure to reduce the risks of transmitting microorganisms from one person to another or from one site to another on the same patient/resident. Review of the information of a sign posted on above resident rooms indicated: STOP Enhanced Barrier Precautions - Everyone Must: Clean their hands, including before entering and when leaving the room. On 10/3/23 at 8:10 a.m., Registered Nurse (RN) #1 prepared medications to be administered to Resident #337. A sign on Resident #337's door stated the resident was on Enhanced Barrier Precautions. The RN entered the resident's room with the medications and failed to sanitize/wash his/her hands before they entered the room. On 10/3/23 at 8:20 a.m., Licensed Practical Nurse (LPN) #2 prepared medications to be administered to Resident #91. A sign on Resident #91's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before he/she entered the room. On 10/3/23 at 8:32 a.m., LPN #2 prepared medications to be administered to Resident #3. A sign on Resident #3's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before he/she entered the room. On 10/3/23 at 8:47 a.m., LPN #2 prepared medications to be administered to Resident #46. A sign on Resident #46's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before they entered the room. On 10/3/23 at 9:07 a.m., LPN #3 prepared medications to be administered to Resident #96. A sign on Resident #96's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before she entered the room and prior to exiting the room. On 10/5/23 at 9:30 a.m., the Infection Control (IC) Nurse stated nurses were to sanitize his/her hands immediately before entering and prior to exiting a resident room to provide care. On 10/5/23 at 9:40 p.m., the Director of Nursing (DON) stated the nurse must hand sanitize their hands before they entered a room and prior to leaving the room.

Based on observation, interview and review of maintenance logs, the facility failed to ensure three (3) of three (3) dryers in the facility's laundry room were free of lint build-up on the dryer vent hose and wall behind the dryers. The findings include: An observation in the facility's laundry room with the facility's Assistant Director of Nursing (ADON) present on 10/6/23 at 11:40 a.m., revealed the dryer vent hose attached and extending from the back of three (3) commercial size dryers were covered with a layer of lint. On one (1) of the hoses was an old fabric softener sheet. Continued observation revealed there was lint build-up on the lower part of the wall behind the three (3) dryers, as well. During an interview at this time, the ADON confirmed the observation of the lint build-up and fabric softener sheet on the hose and wall behind the dryers. In an interview on 10/6/23 at 11:46 a.m., Laundry Staff revealed laundry staff was responsible for cleaning the lint from the front compartments of the dryers and maintenance staff were responsible for cleaning the lint that accumulated behind the dryers. An interview on 10/6/23 at 11:57 a.m. with the facility's Maintenance Director confirmed laundry staff were responsible for removing lint from the front of the dryers in between loads and maintenance staff were responsible for removing lint from the back of the dryer once per month. The Maintenance Director stated, it's coming due again. Continued interview revealed that this cleaning was documented and kept in a logbook. The Maintenance Director said that the lint accumulated quickly on the outside of the dryer vent hose and wall behind the dryers. He/she said maintenance was mostly concerned about lint accumulating on the inside of the vent hose. An observation on 10/6/23 at 12:05 p.m. with the Maintenance Director present was made in the laundry room. The Maintenance Director confirmed there was lint build-up behind the dryers on the hose and wall. He/she stated he/she had seen it worse than that. With his/her right hand index finger and thumb, the Maintenance Director picked up a small clump of lint from the hose behind the dryer, and picked up the fabric softener dryer sheet that was on the hose as well. When the surveyor touched the fabric softener sheet, it was warm and hard. At 12:10 pm on 10/6/23, the Maintenance Director provided documentation for the last monthly log check for the dryers and stated, it's time for a check again. Review of Monthly, Check dryer form dated 9/8/23 revealed Dryers #1, #2 and #3 were last checked and cleaned on 9/8/23.

Based on record review, observations, and interviews the facility failed to provide the necessary services to a dependent resident who was not able to carry out Activities of Daily Living (ADLs) for one (1) of two (2) residents reviewed for ADL care. Specifically, the facility failed to ensure the resident received personal hygiene daily to include combing and removing foreign debris from the resident's hair. (Resident #101) Findings include: Review of the Nursing Policies and Procedures with the subject of Activities of Daily Living, Optimal Function revised 5/5/23 read: The Definition of ADLs refers to tasks related to personal care including, grooming, dressing, oral hygiene . The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Record review revealed Resident #101 was readmitted to the facility on [DATE] with diagnoses that included: Acute Osteomyelitis on the right ankle and foot, Direct Infection of the right ankle and foot, and Infectious and Parasitic diseases. Review of the Annual Minimum Data Set (MDS) assessment, dated 12/29/22, revealed resident's Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating he/she had moderately impaired cognition. The resident's daily preferences were assessed to be very important in relation to the resident choices which included: what clothes to wear, taking care of personal belongings or things, choose between a tub bath, shower, bed bath, or sponge bath. The Resident's Functional status for personal hygiene was extensive with one (1) person assist and bathing was total dependence with one (1) person assist. Review of the Care Plan, which was revised on 10/3/23, identified that Resident #101 had mobility and visual impairments that affected his/her ability to perform ADL tasks and required staff assistance with ADL needs. The approaches included, staff was to assist or provide ADL care needs for Resident #101 routinely, as needed and as tolerated. Review of the Physician Orders included: Start date 4/13/21, bathing assist with one [1] staff. Start date 4/13/21, dressing and grooming assist with one [1] staff. Review of the progress notes from 7/1/23 to 10/5/23 did not reveal any resident refusals for care and assistance with daily personal hygiene to include combing his/her hair. During an observation on 10/3/23 at 10:39 a.m., Resident #101 was waiting to go to Dialysis. His/her hair was disheveled and contained copious amounts foreign debris that appeared to be lint balls. During an interview and observation on 10/5/23 at 9:27 a.m. The resident stated he/she cared about his/her presentation. He/she stated that the staff did not assist with combing his/her hair and was not aware of the lint balls in hair, because he/she had trouble seeing. During an interview on 10/6/23 at 9:36 a.m., Certified Nurse Aide (CNA) #1 stated he/she assisted residents with completing ADL tasks that residents were unable to complete themselves. CNA #1 stated they tried to encourage independence and some residents could not comb their hair or wash areas they could not reach. CNA #1 stated the resident sometimes refused ADL care. He/she didn't think the resident's hair was too bad. During an observation with CNA #1, he/she looked at Resident 101's hair and stated there was lint in the resident's hair in multiple areas. During an interview on 10/6/23 at 9:45 a.m., the Licensed Practical Nurse/Unit Manager (LPN) #4 stated ADL care included washing residents' hair, brushing their teeth, and washing their face. He/she stated, basically head to toe care, including getting dressed and equipping glasses and hearing aids. LPN #4 stated, that if the resident refused; the CNA would tell the nurse, the nurse would ask the resident, if still refused then reapproached later. The LPN said, the resident had multiple personalities and the surveyor may not have been talking to the right person. LPN #4 stated he/she did not know if Resident #101 had lint balls in their hair. He/she stated the resident was able to comb their hair. LPN #4 said, I have not seen lint in the resident's hair. LPN #4 stated he/she did not look at the resident because he/she was too busy passing medication. LPN #4 did not complete an observation with the surveyor because he/she was passing medication. During an interview on 10/6/23 at 10:25 a.m., the Director of Nursing (DON) said ADL care included showers/baths, brush teeth, brushing hair, and added the resident's hair was combed daily unless they refused. The DON observed Resident 101's hair and stated the staff should have assisted with removing lint balls from his/her hair. The DON stated it was important to comb and provide care to residents to prevent sores in the resident's head and to keep the resident's hair from being matted together.

Based on observation, interview, and clinical record review, the facility failed to ensure bilateral hearing aids were applied in accordance with a nursing order; and failed to identify hearing aids were lost/missing for one (1) of 28 sampled residents (Resident #47). The findings include: In an attempted interview during initial tour on 10/3/23 at 10:01 a.m., Resident #47 did not respond to questions asked by this Surveyor. Resident #47 stated he/she could not hear. Review of the Resident #47's clinical record revealed an admitted [DATE], with diagnoses including Unspecified Dementia and Bilateral Acute Otitis Media. Resident #47's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty hearing and utilized hearing aids. According to the assessment, the resident was moderately cognitively impaired having scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #47 did not receive any therapy services during this assessment period. Review of Resident #47's Communication Care Plan initiated on 9/4/2020 and last reviewed on 10/3/23 revealed the following: Problem: [Resident] is hearing impaired in both ears. Goal: [Resident] will hear and understand communication appropriately through next review. Approach: Utilize dry erase board for communication as tolerated; Obtain resident's attention before speaking; Face the resident when speaking; Repeat phrases as needed; Rephrase if necessary; Speak clearly and adjust tone as needed; If refuses to wear hearing aid, explore reason for refusal (9/22/21). Goal: [Resident] will hear and understand communication through next review. Approach: [Resident] to wear bilateral hearing aids/amplifier as tolerated (9/4/2020); Referrals to audiologist as needed; Provide quiet, non-hurried environment, free of background noises and distractions; Place in front of room during group activities; Obtain resident's attention before speaking; Face the resident when speaking; Repeat phrases as needed. Rephrase if necessary; Speak clearly and adjust tone as needed; If refuses to wear hearing aids, explore reason for refusal (9/4/2020); Check that hearing aid(s) is clean, functioning and properly placed into___ (left, right, both) ear(s) (9/4/2020). Review of Resident #47's Nursing Orders, revealed an order for bilateral hearing aids was initiated on 8/26/2020 by a facility Licensed Practical Nurse (LPN) and noted the use of the hearing aids was to be listed in the resident's Activities of Daily Living (ADL) Flow Sheet. Continued review revealed this order was discontinued on 10/5/23 at 12:31 p.m. by the Unit Manager (UM) and noted the resident's [Responsible Party/adult child] picked up hearing aids last time [he/she] came. Review of Resident #47's Nursing Progress Notes revealed the following: 8/26/2020 - Resident admitted to [facility from hospital]. Arrived at 6pm and admitted to room [ROOM NUMBER]. Report given from [Registered Nurse] RN. Resident [was] alert and oriented with some intermittent confusion. Resident [was] pleasant and cooperative with care. Resident [could] not hear well despite having bilateral hearing aids. Able to read lips. 9/4/2020 - Body Audit: Resident alert and able to make needs known to staff, wearing bilateral hearing aids, no drainage noted from eyes, ears, or nose, partial upper denture and natural teeth on bottom . 10/5/23 at 12:34 p.m. - Resident's hearing aids not in room or on resident. RP [Responsible Party] [adult child] inform[ed] staff that [he/she] retrieved the hearing aids on [his/her] last visit. Order discontinued. An interview on 10/5/23 at 11:55 a.m. with the resident's Unit Manager (UM), an LPN, revealed the resident did not consistently or regularly wear his/her hearing aids. The UM stated that, Resident #47 started off the day wearing the hearing aids and then independently removed them from his/her ears during the day. The UM stated that, Resident #47 knew how to store the hearing aids and put them away correctly. Observation and interview with the resident on 10/5/23 at 12:10 p.m. revealed the resident self-propelled down the hallway in a manual wheelchair. The resident was not observed wearing hearing aids. When asked about his/her hearing aids, Resident #47 responded and said, I can't hear but I can see. The resident continued and said, I don't wear hearing aids. An interview on 10/5/23 at 12:10 p.m. with Certified Nursing Aide (CNA) #2, revealed the aide had been employed by the facility for years. The aide said he/she was not aware that Resident #47 wore hearing aids. CNA #2 said he/she had not seen [Resident #47] with any [hearing aids]. An interview on 10/5/23 at 12:20 p.m. with the Activities Director (AD), revealed the staff was not aware the resident wore hearing aids. The AD said that the resident's RP may have taken the hearing aids on his/her last visit around the first of September 2023. An observation in Resident #47's room at 12:20 p.m. on 10/5/23, revealed the resident's UM searched the resident's room (including the roommate's side of the room) in search of the resident's hearing aids. The UM could not find the hearing aids. He/she said the hearing aids should have been locked in the nurses' cart. An interview on 10/5/23 at 12:32 p.m. with the Assistant Business Office Manager (ABOM), revealed the staff called the resident's RP, and the RP reported that he/she had taken the hearing aids away some time ago because his/her mother could not hear with or without them. The ABOM stated the UM was currently discontinuing the resident's order for the bilateral hearing aids. In a follow-up interview on 10/5/23 at 2:50 p.m., the UM revealed he/she discontinued the hearing aids after the ABOM told him/her the RP had taken the hearing aids with him/her. The UM stated the use of the hearing aids was initiated as a nursing order and did not require physician involvement to discontinue the order. An interview with Resident #47's RP on 10/5/23 at 3:03 p.m. revealed he/she had spoken with an employee from the facility earlier in the day. The RP said that he/she told the facility staff that when Resident #47 initially received the hearing aids, the doctor informed the RP that the resident may not be able to hear even with the hearing aids because his/her hearing was so bad. The RP said that he/she did not have the hearing aids and did not take them away from the resident on his/her last visit. The RP also said that he/she did not tell the facility's employee (ABOM) that he/she had taken the hearing aids away. The RP said that he/she would prefer that Resident #47 received another set of hearing aids if it would not be too costly. An interview on 10/5/23 at 3:37 p.m. with the facility's Director of Nursing (DON) revealed the UM informed him/her earlier in the day that the resident's RP had taken the hearing aids on his/her last visit and that the assistive devices were discontinued. He/she said that the hearing aids were a Nursing Order which did not require physician involvement to discontinue the devices. When informed that the resident's RP said that he/she did not retrieve the hearing aids, the DON said that the expectation would now be for the UM to set up an audiology appointment and if the hearing aids were lost on behalf of the facility then the facility would replace the hearing aids. The DON said that staff should have discovered that the hearing aides were missing before Surveyor intervention. The DON said that nursing aides were made aware that Resident #47 required the use of hearing aids because that information appeared in the electronic kiosk/cardex system that the nurse aides accessed to review residents' ADL assistance requirements. The DON said nursing aides were not required to sign off that they assisted with placing the hearing aids on Resident #47. In an interview on 10/5/23 at 5:15 p.m., the DON revealed he/she had a follow up call with the resident's RP. The DON said the RP informed him/her that he/she told the ABOM that Resident #47 left the hearing aids at their last placement before being admitted into the current facility.

Based on observations, interviews, and facility policies and procedures reviewed, the facility failed to ensure that the meals served were palliative, offered at an acceptable temperature, and delivered in a timely manner. Specifically, the facility was serving residents food that was not appetizing, cold in temperature, and given after the times that meals were supposed to be offered. There were also residents that received their meals long after other residents that reside in the same room as well as in the dining hall. Findings include: 1. According to the Assistant Certified Dietary Manager (CDM), the mealtimes for each unit in the facility are as follows: Breakfast: [MEDICATION(S)] First Cart 8:00 AM [MEDICATION(S)] Second Cart 8:20 AM Magnolia Dining Room Cart 8:35 AM Magnolia Middle Cart 8:50 AM Magnolia Back Cark 9:05 AM Indigo First Cart 9:15 AM Indigo Second Cart 9:35 AM Lunch: [MEDICATION(S)] First Cart 12:00 PM [MEDICATION(S)] Second Cart 12:20 PM Magnolia Dining Room Cart 12:35 Magnolia Middle Cart 12:50 PM Magnolia Back Cart 1:05 PM Indigo First Cart 1:15 PM Indigo Second Cart 1:35 PM Dinner: [MEDICATION(S)] First Cart 5:00 PM [MEDICATION(S)] Second Cart 5:20 PM Magnolia Dining Room Cart 5:35 PM Magnolia Middle Cart 5:50 PM Magnolia Back Cart 6:05 PM Indigo First Cart 6:15 PM Indigo Second Cart 6:35 PM Dinner was observed being served to the residents on the Magnolia unit on 08/15/2021. The first tray in the Magnolia dining room was delivered at 5:59 PM, first tray to be delivered on the unit (Room 201) was at 5:58 PM, room 210 received their tray at 6:09 PM, and the last room on the unit received their tray at 6:27 PM. A test tray of both a regular lunch meal and a pureed lunch meal was given to the survey team on 08/17/2021 at 1:48 PM. The menu consisted of for the pureed tray, mashed potatoes with gravy, pureed vegetables, pureed chicken, lime fat free sherbet, tea, and water with a salt and pepper packet included. The regular meal tray consisted of teriyaki chicken, mixed vegetables, white rice, lime fat free sherbet, tea, and water along with a salt and pepper packet included. The food on the pureed tray was barely warm, the vegetables tasted like it was only pureed carrots, the mashed potatoes were barely warm as well, pureed chicken tasted like fried chicken. The regular meal tray was a little warmer than the pureed tray, but both trays were not at a temperature that a resident could enjoy the food. There was no seasoning on the pureed foods, but the regular meal did have a little seasoning. Overall both test trays were not at a desirable temperature and quality was poor. There had been many complaints in regard to the quality of the food and the food being cold. An interview was conducted with Facility Administrator, and the Director of Nursing (DON) on 08/18/2021 at 9:15 AM about the expectations on meal service and meal service times. The Administrator stated that he/she does allow a ten-to-fifteen-minute leeway time for the CNA's or other staff to get the food trays to the residents' rooms. All the CNAs are supposed to have walkie talkies so that they will know when the food carts are being brought out by the kitchen staff to the specified units announced over the walkie talkie system. DON stated that independent residents get their food trays first, then the staff comes back to the food carts and start to hand out the residents that are dependent and need to be fed after all the other residents' trays have been passed out. The CDM stated that the trays are different colors (pink, red, and yellow) in order to let the staff know whether or not the resident will need assistance with eating their meals. Pink is for residents that can eat by themselves, red is for residents that are Feeders ( need to be fed by staff), and yellow is for residents that need assistance (open milk, cut up food, get out the straw, etc.) Review of the facility's policy and procedure titled, Nutrition Policies and Procedures with the subject of Meal Delivery, last revised on 10/07/2017 states that Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to improved appetite and can enhance quality of life. Room trays will be delivered promptly to maintain food temperatures. According to the policy the following procedures are not being followed: #2 Make every effort to deliver the trays at the same time each day so patients/residents and nursing staff can anticipate the approximate arrival time. #4 Schedule staff mealtimes around the patient/resident mealtime so that an adequate amount of nursing staff is present and available to assist patients/residents. This will ensure that the food is delivered to the patient/resident at the proper temperature and that there is enough monitoring of those residents who require assistance, reminders, and/or direction. #8 Pull trays from the cart in the order they are set up; staff is discouraged from hunting for a tray. Nursing unit manager and Nutrition/Culinary Services Director develop a list for proper tray delivery order that nutrition services use to set up the carts. #10 Pass meals promptly upon tray cart's delivery to the nursing unit. #16 Serve patients/residents seated together their meal at the same time. In a review of R38's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 06/02/21, revealed R38 was admitted on [DATE] with diagnoses including but not limited to, acute and chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)], adult failure to thrive, and major depressive disorder. The resident's Brief Interview for Mental Status (BIMS) was 15, indicating cognitively intact. An interview with R38 on 08/15/21 at 05:03 PM, revealed his/her food is often cold and he/she asks to get the food warmed up. In an observation on 08/17/21 at 09:28 AM, R38 received his breakfast in a Styrofoam container. He was given two sausage links, scrambled eggs, grits and toast. When the Styrofoam container was opened R38 proceeded to touch his/her grits with his/her finger and take a bite of his/her sausage. He/she then asked the nurse's assistant to heat up the meal. R38 stated the food was cold. In an observation on 08/18/21 R38 food arrived in the cart on the unit at 09:07 AM. He/she received his/her tray at 09:32 AM. The food was in a Styrofoam container. His/her breakfast consisted of two sausage links, scrambled eggs, grits and toast. R38 took a bite of one sausage link and eggs and proceeded to ask for the food to be warmed up. In a review of R65's quarterly MDS, with an ARD of 06/16/21, revealed R65 was admitted on [DATE] with diagnosis including but not limited to, acute chronic heart failure, end stage renal disease, and pulmonary hypertension. The resident's BIMS was 13, indicating cognitively intact. An interview with R65 on 08/16/21 at 10:27 AM, revealed his/her food is always lukewarm adding it was as if the food was sitting on the plate for a while before he/she received it. On 08/17/21 at 09:32 AM, R65 revealed his/her breakfast was was not hot and was not cold. He/she stated he/she would prefer the food to be warmer. On 08/18/21 at 09:52 AM, R65 stated his/her food was lukewarm again. In an interview with Unit Manager (UM) #1 revealed R38 often complains of getting cold food and needs to get it warmed up. UM #1 added R65 often complains of the food temperature as well.

Based on interview, record review, and review of facility policy and procedure, the facility failed to secure personal and confidential information for residents and staff of the facility. This had the potential to allow confidential information protected by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to be used for personal and/or public intentions. Findings include: Review of facility handbook titled, Admission Handbook dated 07/01/21 revealed, .South Carolina Law Resident's Rights .6. Each resident must be assured security in storing personal possessions and confidential treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/18/21 at 9:32 AM in an interview with the Medical Records Coordinator revealed that a Request paper is filled out and a copy of the form is sent to corporate. Corporate will notify if approved or not to be sent released. I go into the computer and whatever is being requested I let the Director of Nursing (DON) review it and sometimes we mail it or email it. If it's a lot of paperwork, I just email it but if it's not a lot then I will keep a copy of what was sent . On 08/18/21 at 9:45 AM in an interview with certified nursing assistant (CNA) 2 revealed that s/he was the previous medical records coordinator. S/he stated that the information for R 343 was picked up by the resident representative. On 08/18/21 at 7:14 PM in an interview with R 343's representative it was stated that the facility provided other resident and staff information to me that I should not have had. On 08/18/21 at 8:00 PM R 343's representative provided the surveyor with documentation that revealed and included a resident facility incident detail report, Resident Covid 19 status and Facility Staff Covid 19 status.

Based on observations, record reviews and interviews the facility failed to assure the proper medfication storage and removal of expired medications in 2 of 3 medication rooms. The findings include: -On 8/15/21 at approximately 3:49 PM inspection of the Indigo Medication Room Refrigerator revealed two reconstituted bottles of First - [MEDICATION(S)] 2 mg (milligram)/ml (milliliter) Oral Suspension belonging to Resident # 61. Bottle # 1 with lot number was approximately 2/3 full and dated by the facility to expire on 7/26/21 and Bottle # 2 with lot number was approximately 1/10 full and was not dated by the facility as to expiration date. This finding was verified by LPN (Licensed Practical Nurse) # 1 -On 8/15/21 at approximately 4:11 PM inspection of the [MEDICATION(S)] Medication Room Refrigerator revealed one opened and reconstituted 100 ml bottle of E.E.S. ([MEDICATION(S)]) Oral Suspension 200 mg/5 ml with pink dried substance around bottle cap and down sides of the bottle This finding was verified by LPN # 2 who proceeded to clean the exterior of the bottle.

Based on observations, interviews and review of the facility policy titled, Nutrition Policies And Procedures. the facility failed to ensure residents were served meals sequentially during 2 of 2 meal observations on 3 of 3 Units. The findings include: An observation on 8/15/2021 at 5:21 PM of the dinner meal on the [MEDICATION(S)] Unit revealed 4 residents sitting at one table. One resident was served dinner and began eating. The three other residents were not served for over 10 minutes when the second meal cart was brought to the [MEDICATION(S)] Unit. The resident that had received his/her tray first was finished eating before the other 3 residents received their dinner trays. An observation on 08/15/21 at 6:40 PM revealed supper trays were delivered to Hall 100 by the dietary staff. An observation on 08/15/21 at 6:50 PM revealed the resident in room [ROOM NUMBER] A received his/her supper tray and the resident in 118 B was not served a tray. An observation on 08/15/21 at 7:00 PM revealed Resident 118 B did not have a supper tray when the surveyor left the floor. An observation on 08/16/21 at 9:06 AM revealed Resident 118 A with a breakfast tray and Resident 118 B with no breakfast tray. An observation on 08/16/21 at 9:21 AM revealed Resident 118 B with a breakfast tray. On 08/16/21 at 11:50 AM in an interview with Certified Nursing Assistant (CNA) 4 revealed that We normally pass trays out from one end of the hall to the other. We try to pass them out from one room to the next. The feeder trays (those we feed) we leave them on the cart and go back and feed them. A second observation on 8/17/2021 at 12:45 PM of the lunch meal service on the [MEDICATION(S)] Unit revealed table with 2 or more residents were being served at random times while the residents left without a tray at the same table were observing the residents eat that had already received their trays. The tables were not served sequentially for residents awaiting lunch trays with residents that had already received their lunch trays. An interview on 8/17/2021 at approximately 1:05 PM with the Licensed Practical Nurse (LPN) Unit Manager on the [MEDICATION(S)] Unit, confirmed that lunch trays were randomly served to residents at tables with 2 or more residents that were awaiting trays and watched other residents at the same table eat lunch. Review on 8/17/2021 at approximately 2:00 PM of the facility policy titled, Nutrition Policies and Procedures, under, Meal Delivery, Procedures: Number 16 states, Serve patients/residents seated together their meal at the same time.

Based on interview, record review, and review of facility policy and procedure, the facility failed to ensure one (Resident (R) 343) of three resident representative was provided the right to participate in treatment care. This failure had the potential to prevent the resident representative from the ability to consent or decline treatment options for R 343's treatment plan. Findings include: Review of facility policy titled, [CONDITION(S)] Drugs-Use Of dated 11/1/17 revealed, . 6. A consent form will be completed for each [CONDITION(S)] medication prescribed. Documentation should include if the intended or actual benefit is understood by the resident and, if appropriate, his/her family and/or representative(s) and is sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication, dose, and duration. Consents can be obtained in two ways: A, Resident/patient or their legal representative's given written consent, which includes provision of risk and benefits information and signature on the facility approved consent form. This form will be kept in the resident's/patient's chart. B. Telephone consents are acceptable when the required information was discussed with the resident/patient or legal representative and documented in the chart. If telephone consent is received, it required the signature of two witnesses .7. D. When psychopharmacological medications are used as an emergency measure, adjunctive approaches, such as individualized, non-pharmacological approaches and techniques must be implemented . Review of R 343's electronic medical record (EMR) Face Sheet dated 11/18/20 revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 343's EMR Care Plan dated 11/18/2020 revealed, Resident/responsible party will be informed of any changes in residents condition and benefits, risk and possible choices of treatment. Review of R 343's EMR Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of EMR nursing Resident Progress Notes dated 12/23/20 at 1:39 AM, revealed, Resident O2 (oxygen) at 79 without ordered 4L (liters) NC (nasal cannula) on. 11:40 PM res (resident) noted to remove IV (intravenous) and NC (nasal cannula). Sats (saturation) read at 82% (percent) RA (room air). MD (medical doctor) notified and ordered 25 mg (milligram) of [MEDICATION(S)] PO (by mouth) x 1 dose for agitation. [MEDICATION(S)] was administered with effective results. Res (resident) rested with cannula in place with sats at 96 4L NC . Review of R 343's EMR Care Plan revealed R 343 was not care planned for a [CONDITION(S)] medication. During an interview with the Unit Manager (UM) on 08/17/21 at 3:35 PM, s/he stated that medication changes of a resident is relayed to the representative by the nurse. They will get the order, put the order in the computer, and then call the representative and let them know. The nurses are to document that they contacted the representative. If I don ' t see the documentation, then I will call the representative the next day personally and make them aware. [CONDITION(S)] medications are the only medications requiring a resident or resident representative consent for the meds. [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] also require consents prior to administration. During a telephone interview with the complainant/resident representative on 08/17/21 at 7:14 PM, s/he stated that they never told me about any changes and what was going on. Nearly everyone staff and patients had Covid during the time that my mom was there. Once he/she got Covid they said someone would call often and let me know how he/she was doing. They would have a different person everyday taking care of him/her. I think the changes in his/her medications is ultimately what caused him/her to have the issues he/she did at the end.

Based on interview, record review, and review of facility policy and procedure, the facility failed to ensure that two (Residents (R) 109 and 114) of five residents reviewed for care planning involved the Interdisciplinary team members. Subsequently, there was no documentation of involvement and/or approval of the care plan by the medical director. This failure had the potential to prevent the residents from experiencing their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of facility policy, Person Centered Care Plan Process dated 07/01/16 revealed, .8. The IDT (Interdisciplinary) includes but is not limited to: A. A registered nurse with responsibility for the resident. B. A nurse aide with responsibility for the resident. C. A member of food and nutrition services staff. D. The attending physician E. Other appropriate staff or professional in disciplines as determined by the resident's needs or as requested by the resident . 1. Review of R 109's Electronic Medical Record (EMR) Face Sheet dated 06/19/21 revealed R 109 was admitted to the facility with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 109's EMR Care Plan Conference Summary dated 07/27/21 revealed R 109's participants consisted of a licensed practical nurse (LPN), resident representative, resident, certified nursing assistant (CNA), DSS (Department of Social Services) representative, registered nurse, clinical data manager, and certified physician assistant. Review of R 109's EMR physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of R 114's EMR Face Sheet dated 05/29/20 revealed R 114 was admitted to the facility with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 114's EMR Care Plan Conference Summary dated 07/27/21 revealed R 114's participants consisted of a LPN, resident representative, CNA, DSS representative, registered nurse, clinical data manager, and certified physician assistant. Review of R 114's EMR Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/16/21at 2:13 PM in an interview with the Minimum Data Set Coordinator revealed I normally write up the conference summary sheet post the assessment of the resident. I send a letter to the resident representative and hospice (if involved) via mail. We give the resident an invite. Social services calls the family to contact them prior to the meetings as a 2nd layer of communication. Usually Social services, dietary, activity director, MDS coordinator, resident representative if available will attend. The MD will sign the care plan sheet once reviewed . We put it in the doctor's book for them to look at and sign. Once signed I check it off and give to the medical records person to scan in the chart. On 08/18/21 at 11:34 AM in an interview with the Certified Physician Assistant revealed during the care plan meetings I go over meds (medications), recent labs, therapy goals and answer any questions they may have. The Medical Director sees long term care once every other month and if there are any concerns, then s/he will come once a week and I will review any changes with him/her. I usually sign off on the care plans.

Based on observations, record keeping, interviews and the 2017 ISMP (Institute for Safe Medication Practices) Guidelines for Optimizing Safe Subcutaneous Insulin in Adults the facility failed to coordinate FSBS (finger stick blood sugar) glucose monitoring with meal deliveries and the administration of rapid-acting insulin ([MEDICATION(S)]) for 1 (Resident # 47) of 5 residents reviewed for unnecessary medications. The findings include: -On 8/16/21 dinner on a red tray was observed to be delivered to Resident # 47 at approximately 6:30 PM, on 8/16/21 and 8/17/21 lunch was delivered at approximately 1:20-1:25 PM and on 8/17/21 breakfast was delivered at approximately 9:05 AM. On 8/17/21 Registered Nurse (RN) # 1 was observed entering the room of Resident # 47 at approximately 11:10 AM to perform FSBS (finger stick blood sugar) glucose monitoring on Resident # 47. Resident # 47 had been readmitted to the facility on [DATE] and placed on contact precautions on the Indigo Front Hall, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -On 8/17/21 at approximately 10:20 AM a medical record review for Resident # 47, Indigo Front Hall, revealed an open ended physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the of the facility's Meal Cart Times Revised 6/24/2021 revealed scheduled deliveries for the Indigo 1st Cart at breakfast was 9:19 (AM), Lunch 1:15 (AM) and Dinner 6:15 (PM). -On 8/17/21 at approximately 12:20 PM, the DON (Director of Nursing) acknowledged the findings and stated that insulin should be administered 15-30 minutes before meals and concurred that there is too much time between finger stick blood sugar checks being done, Novolog insulin being administered if needed and meals being served and that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2017 ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults states in 3.1: Organizations should develop a coordinated process to ensure timely blood glucose checks and administration of NUTRITIONAL INSULIN ([MEDICATION(S)] (insulin [MEDICATION(S)]) and Novolog (insulin [MEDICATION(S)]) in conjunction with meal delivery. A lack of coordination between meals, glucose checks, and insulin administration can have a significant impact on the effectiveness of diabetes management and the prevention of hyper- and [CONDITION(S)]. Variability in the timing of any of these segments of care can lead to harmful outcomes for the patient. Clear organizational guidance and standardization is the key to success in this practice.

Based on review of facility files and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Resident #5 and Resident #5 were noted to have 2 incidents of physical altercation. The facility failed to respond to those incidents to protect the residents from further incidents. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in her/his room trashcan and/or in the A/C unit in her/his room, smearing bodily wastes on the wall(s), etc.) S/He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]5 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from abuse. Resident #5 and Resident #6 were noted to have two altercations that involved physical abuse. The facility failed to implement interventions to prevent the abuse. 2 of 4 residents reviewed for resident to resident abuse. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in her/his room trashcan and/or in the A/C unit in her/his room, smearing bodily wastes on the wall(s), etc.) S/He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]0 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #5 and Resident #6 were noted to have 2 altercations that involved allegations of physical abuse. The facility did not have interventions in place to protect Resident #6 from harm from Resident #5. 2 of 4 residents reviewed for resident to resident abuse. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making. Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in his room trashcan and/or in the A/C unit in his room, smearing bodily wastes on the wall(s), etc.) He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. Review of the facility's policy on Abuse, Neglect, Exploitation, or Mistreatment indicated the facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse and will implement immediate action to safeguard resident. Prevention included ongoing assessment, care planning, and monitoring of those residents with special needs that may lead to neglect to include those with history of resident to resident altercations. Physical abuse was noted to include hitting, slapping, pinching, and kicking. In the event another resident is accused of abuse/neglect against a resident, the facility will intervene and take appropriate steps to safeguard the resident during and after the investigation. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]7 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.

Based on review of facility files and interview, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Resident #5 and Resident #6 were noted to have two physical altercations on separate occasions. There was no documentation in the resident's medical records related to the incidents by social services. 2 of 4 residents reviewed for resident to resident abuse. The findings included: Cross refer to F0[AGE]0 Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. Resident #5's Progress Notes were reviewed from 5/22/18 - 9/6/18 and revealed multiple incidents of behaviors. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week.Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August.The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. Resident #6 ' s [DIAGNOSES REDACTED]. Review of Resident #6's medical record revealed a Progress Note on 8/25/18 at 7:27 AM that indicated the resident's responsible party wanted to speak with Social Services on Monday. The responsible party was called to notify them about the incident on 8/25/18 with Resident #5. There was no documentation in the resident's medical record by Social Services on 8/25/18 or after. Resident #6's Progress Notes were reviewed 7/2/18-9/4/18. There were 2 notes documented by Social Services in July related to the resident's level of care. There were no other notes from Social Services. It was revealed during an interview with the surveyor on 9/6/18 at approximately 4:35 PM with the DON (Director of Nursing) that after Resident #5 started with behaviors towards Resident #6, Resident #6 started having behaviors. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Review of the facility's Abuse, Neglect, and Misappropriation of Property revealed the guidelines for investigation included Social Service will provide support services to the resident and implement an interdisciplinary care plan. Review of the facility's Dementia policy revealed staff will be adequately trained to provide necessary care and services that is person centered. Social services assess and identify resident specific needs and approaches during the initial assessment period and ongoing and needs are evident. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0745 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.

Based on review of facility files and interview, the facility failed to review and revise care plans. Resident #5 had two incidents of physical behavior toward Resident #6. The resident's care plan was not updated to reflect the incidents. 1 of 7 residents reviewed for care plans. The findings included: Cross refer to F0[AGE]0. Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident, that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in his room trashcan and/or in the A/C unit in his room, smearing bodily wastes on the wall(s), etc.) He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0657 at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.

Based on review of facility files and interview, the facility failed to ensure that a resident who displays or is diagnosed with [REDACTED]. Resident #5 was noted to have increased behaviors and the facility failed to ensure the resident received appropriate treatment and services. 1 of 4 residents reviewed for resident to resident abuse. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident, that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in his room trashcan and/or in the A/C unit in his room, smearing bodily wastes on the wall(s), etc.) He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. The facility provided a list of residents seen by the Geriatric psychiatry Nurse Practitioner in July and August 2018 to the surveyor on 9/7/18. Resident #5 was not on the list as being seen by the nurse practitioner. The list also contained the names of residents who were to be seen by the Geriatric psychiatry nurse practitioner the following week. The list was reviewed and the surveyor noted Resident #5's name was not on the list. Review of the facility's Documentation of Mood and Behavior Needs policy revealed nursing staff will document in accordance with facility guidelines. Suggested documentation guidelines included behaviors: describe behavior, when do they occur, what task was being attempted, who was around or involved. What happened immediately before the behavior, what happened after the behaviors? What are they? When do they occur? Was there an injury? Get a description of how injury occurs. What occurred? Where was the patient/resident? How are they addressed? How long do they last? Is a behavior-tracking tool utilized on the resident? What interventions are utilized? How long do the interventions last? On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0742 at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.

During the Recertification, Complaint and Extended Survey, based on observation, record reviews, and interviews, the facility Administration failed to effectively protect residents in the facility against the possibility of elopement through windows that opened after an incident of elopement using a window as an egress point. The windows in the facility were identified as 122 in number that remain with open access for residents to unsafe areas. This not only had the potential to affect the two residents reviewed for accidents during the survey (R138 and R132) but also the remaining 18 residents that wear a Wanderguard system due to an elopement risk. Cross reference to F323 Accidents, Hazards/Supervision Cross reference F520 Quality Assurance Findings include: During the survey, Resident (R)138 was triggered for a review under the category of accidents. Progress Notes were reviewed in R138's record regarding subjects including: -wandering to other resident's rooms -verbal altercations with staff and other residents -physical altercations with staff and other residents -relieving himself in other resident rooms -exit seeking behaviors R138 eloped from the facility via his room window on 1/17/17 and was chased a mile down the road prior to staff reaching him. Observations and interview with a Maintenance Employee (ME) on 3/29/17 at 8:40 a.m. revealed windows still fully open. Interview of ME14 on 3/29/17 at 5:15 p.m. identified 122 windows that would open to an unsafe area. In an interview on 3/29/17 at 3:20 p.m. the Administrator stated after the incident, the Maintenance Director contacted the local Fire Marshall and was told they could not keep the windows from opening and as R138 was no longer there and no other resident's like R138, the issue was dropped. No action was taken. In an interview on 3/29/17 at 3:45 p.m., a Captain from the Georgetown Fire Department and the local Fire Marshall, stated he was the authority having jurisdiction - AHJ and stated that all original design features of windows must be maintained. He stated he was not in this position in January and had not spoken to a facility representative. At 3:50 p.m. the Captain stated he would recommend the facility use alarms but is unaware if that was suggested by his predecessor. A review of R132's record, that also triggered for accident review, revealed Progress Notes after 1/17/17 regarding subjects including: -wandering to other resident's rooms -physical altercations with staff and other residents -relieving herself in other resident rooms -exit seeking behaviors R132 does wear a Wander Guard alarm bracelet due to her elopement risk; and the opinion of a nursing staff member that R132 would be able to physically open a window. Administration did not identify the similarities between the two residents and, therefore, the potential of elopement via an open window continued. In a meeting on 3/29/17 at 3:20 p.m. between the Administrator, DON, Clinical Consultant, and Survey Team the facility was notified of the Immediate Jeopardy existing related to F490 Effective Administration/resident Well-Being as of January 17, 2017. Resident 132 was demonstrating many of the same types of behaviors exhibiting by Resident 138 prior to his elopement and the facility Administration failed to ensure an intervention for the potential of the use of a window as a point of egress for other residents was identified. On 3/30/17 at 1:30 p.m. the facility provided a written plan of action to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: Previously identified resident that exited facility through resident room window on 1/17/17 was immediately discharged to Georgetown Memorial Hospital at time of incident. No other facility residents had previously exited through a resident room window prior to 1/17/17. There have been no other elopements from the facility since 1/17/17. All facility residents have been validated to be present in the facility on 3/29/17 at 4:05 p.m. by the facility Assistant Director of Nursing, with 4 residents being out of the facility for appropriate reasons known to staff. Residents in the facility identified as elopement risk are being monitored by facility nursing staff every 15 minutes to validate they are not exhibiting exiting seeking via facility windows. This monitoring was initiated on 3/29/17 at 3:45 p.m. and will continue until an appropriate intervention is implemented to prevent future exit attempts via facility windows. The facility Staff Development Coordinator has re-educated all facility staff on reporting observation of exit seeking behavior via facility window to nursing leadership or facility administration. This re-education was completed on 3/29/17. Any facility staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. All newly admitted residents will be evaluated for risk of elopement with interventions to be implemented as appropriate. The facility management is actively pursuing an appropriate intervention for facility windows to prevent future exit attempts. The facility Administrator will review all related information for concerns on an ongoing basis. The Director of Nursing will report all findings from audits and monitoring to the Quality Assurance Improvement committee monthly. Any areas of concern will be addressed at the time of discovery for further intervention. Observations, record reviews, and interviews revealed the plan submitted by the facility on 3/30/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. On 3/30/17 at 3:01 p.m. the State Agency accepted the facility written plan of action presented on 3/30/17 at 1:30 p.m. that removed the Immediate Jeopardy. The citation F490 will continue at a lower scope and severity level of D.

During the Recertification, Complaint and Extended Survey, based on observations, interview, and record review, the facility failed to ensure the Quality Assurance (QA) Committee identified a potential elopement egress point and interventions to ensure the safety of residents assessed for potential elopement after Resident (R) 138 successfully eloped through a resident room window. This not only had the potential to affect the two residents reviewed for accidents during the survey (R138 and R132) but also the remaining 18 residents that wear a Wanderguard system due to an elopement risk. The facility census at the time of survey was 127. Cross Reference F323 Accidents Hazards and Supervision Cross Reference F490 Effective Administration/resident Well-Being Findings include: During the course of the survey, Resident (R)138 was reviewed for accidents. Progress Notes were reviewed in R138's record and included notes regarding subjects including: -wandering to other resident's rooms -verbal altercations with staff and other residents -physical altercations with staff and other residents -relieving himself in other resident rooms -exit seeking behaviors R138 eloped from the facility via his room window on 1/17/17 and was chased a mile down the road prior to staff reaching him. Reference findings under F323. Observations and interview with a Maintenance Employee on 3/29/17 5:15 p.m. revealed 122 windows leading to unsafe areas could be fully opened. A review of the facility provided Leadership Policies and Procedures Subject: Elopement, showing a Complete Revision: 5/11/2013 revealed . 11. Facilities Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences. In an interview on 3/29/17 at 11:58 a.m., the Administrator showed documentation that the incident had been taken to the QA committee at the next meeting on 2/10/17. A review of the QA documentation the Administrator presented for the 2/10/17 meeting revealed a sign in sheet of at least 17 attendees. On the last page, in a section titled Safety (identified trends brought to QAPI (Quality Assurance Performance Improvement) from Safety Meeting in the row titled Elopement Drills was a handwritten note that stated *Resident went out window* and a handwritten note at the bottom of the page stated *Resident windows cannot be screwed shut due to fire regs (regulations). Responding to the query regarding number 11 on the Elopement policy, the Administrator stated Not very complete (referencing the handwritten items) and stated R138 was transferred out and not allowed to return was the intervention to prevent reoccurrences. In an interview on 3/29/17 at 3:20 p.m. the Administrator stated after the incident, the Maintenance Director contacted the local Fire Marshall and was told they could not keep the windows from opening and as R138 had been transferred out of the facility, the issue was dropped. In an interview on 3/29/17 at 3:45 p.m., a Captain from the Georgetown Fire Department and the local Fire Marshall, stated he was the authority having jurisdiction - AHJ and stated that all original design features of windows must be maintained. He stated he was not in this position in January and had not spoken to a facility representative. At 3:50 p.m. the Captain stated he would recommend the facility use alarms but is unaware if that was suggested by his predecessor. A review of R132's record, that also triggered for accident review, revealed Progress Notes after 1/17/17 regarding the majority of the same items listed above for R138 (also see F323 and/or synopsis in F490) and R132 had been previously been identified as an elopement risk; who nursing staff felt would be able to open a window. The QA Committee failed to identify another resident that was in house and showing many of the same behaviors as R138; or review the other 18 residents identified as elopement risks and wearing Wander Guard alarm bands to ensure none had behaviors or capabilities that presented risk. The QA Committee failed to search for options to modify the windows while still maintaining the original functionality to prevent reoccurrences. In a meeting on 3/29/17 at 3:20 p.m. between the Administrator, DON, Clinical Consultant, and Survey Team the facility was notified of the Immediate Jeopardy at F520 Quality Assurance existing in the facility as of January 17, 2017. Resident 132 was demonstrating many of the same types of behaviors exhibiting by Resident 138 prior to his elopement and the facility failed to ensure an intervention for the potential of the use of a window as a point of egress for other residents was identified. On 3/30/17 at 1:30 p.m. the facility provided a written plan of action to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: Previously identified resident that exited facility through resident room window on 1/17/17 was immediately discharged to Georgetown Memorial Hospital at time of incident. No other facility residents had previously exited through a resident room window prior to 1/17/17. There have been no other elopements from the facility since 1/17/17. All facility residents have been validated to be present in the facility on 3/29/17 at 4:05 p.m. by the facility Assistant Director of Nursing, with 4 residents being out of the facility for appropriate reasons known to staff. Residents in the facility identified as elopement risk are being monitored by facility nursing staff every 15 minutes to validate they are not exhibiting exiting seeking via facility windows. This monitoring was initiated on 3/29/17 at 3:45 p.m. and will continue until an appropriate intervention is implemented to prevent future exit attempts via facility windows. The facility Staff Development Coordinator has re-educated all facility staff on reporting observation of exit seeking behavior via facility window to nursing leadership or facility administration. This re-education was completed on 3/29/17. Any facility staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. All newly admitted residents will be evaluated for risk of elopement with interventions to be implemented as appropriate. The facility management is actively pursuing an appropriate intervention for facility windows to prevent future exit attempts. The facility Administrator will review all related information for concerns on an ongoing basis. The Director of Nursing will report all findings from audits and monitoring to the Quality Assurance Improvement committee monthly. Any areas of concern will be addressed at the time of discovery for further intervention. Observations, record reviews, and interviews revealed the plan submitted by the facility on 3/30/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. On 3/30/17 at 3:01 p.m. the State Agency accepted the facility written plan of action presented on 3/30/17 at 1:30 p.m. that removed the Immediate Jeopardy. The citation F520 will continue at a lower scope and severity level of D.

During the course of the Recertification, Complaint and Extended Survey, based on observations, interview, and record review, the facility failed to provide interventions to ensure the safety of residents assessed for potential elopement after Resident (R) 138 successfully eloped through a resident room window. This not only had the potential to affect the two residents reviewed for accidents in the course of the survey (R138 and R132) but also the remaining 18 residents that wear a Wanderguard system due to an elopement risk. The facility census at the time of survey was 127. Findings include: 1) A review of R138's Resident Face Sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) revealed a facility admission date of [DATE] with medical [DIAGNOSES REDACTED]. A review of R138's care plan revealed a page with Problem Category: Behavioral Symptoms Resident is at risk for elopement. Problem Start Date: 12/30/2016 Edited: 01/17/2017 The Goal of the page was Resident will wander safely within specified boundaries. Will not have any successful elopements. Created: 01/17/2017 with Approaches (all with a start date of 12/30/2016 and created on 1/17/2017) of: -Approach from the front. Walk in step with resident first before redirecting. -Elopement assessment to be completed quarterly and as needed. -Engage in activities when wandering or elopement attempts occur -Maintain a calm environment and approach to the resident. -Place picture in elopement books. -Remove resident from other resident's rooms and unsafe situations. A review of the Progress Notes in R138's record revealed the following entries: -12/31/2016 11:55AM alert but confused. morning meds tolerated well. res (Resident) likes to roam halls (with and without walker) and visit others. skilled services provided for nursing and rehab. res in therapy gym with therapist. -01/01/2017 12:33AM Res was found in another res's room going through his drawers looking for clothes. 2 person assist to redirect and assist res to his own room. -01/01/2017 5:44AM Res up all night - up and down - taking off clothes and putting back on - check on res - not in room - found in rm (room) 103 - took another res's blanket and was dragging it behind him. Not able to redirect or comprehend instructions such as use of call bell even when demonstrated - cannot return demonstration. -01/01/2017 3:05PM Note(sic): Late entry 1/1/17 2:25 Res wandering constantly down hallway res attempted x 2 to exit doors staff redirected res easily with first attempt from exit doors 2nd attempt to exit door Res stated I'M (sic) getting out of this place and I'm not coming back in this place Md (sic) notified and new order to Move res to Room 322A res continues to stand at indigo (hall name) front door res stated I'm not moving unable to redirect res with redirection methods staff members continues (sic) to monitor resident area clear of objects around resident active rom (range of motion) to extremities res refusing to use walker with ambulation res standing at side of door with back to the door looking into the dayroom at this time 2:30 Res ambulating self in dayroom denies pain or discomfort res cooperative with care refused to ambulate with walker res moved to room 322A res made aware of new order -01/01/2017 6:44PM pt in the unit wandering in the hallway. redirected by staff easily. no aggressiveness noted. confused, reoriented by staff. accompanied by staff to his room. will continue to monitor -01/01/2017 11:02PM Resident alert with confusion. Wandering aimlessly down the halls and in and out of other resident's rooms. Went into room 320 and refused to get out. Going through 320B's belongings and putting on clothes that were not his. Took apart the empty bed and moved the spare dresser into the middle of the floor. Unable to be redirected out of the room even with much coaxing and with one on one. After a couple of hours, resident finally came out of the room. Care provided. Resident now sitting up in chair in dining area. -01/02/2017 6:22AM Resident up most of the night walking in and out of resident's room plundering through their belongings. Slept for half an hour sitting up in the dining area. No combative behavior noted. -01/02/2017 4:20PM Resident visiting with family members. Several attempts to exit seek. Not easily redirected. Took AM medications whole without difficulty. PO (oral) intake good, feeds self with set up from staff. Resident had both left and right hearing aids. Family requested that nurse take hearing aid out each night. N.O. (new order) place to remove hearing aids at bedtime. Extra batteries labeled with residents (sic) room number and placed in med cart. No c/o (complaint of) pain, will continue to monitor. -01/03/2017 4:11PM Resident left unit with therapy at 1300 (1:00PM). Therapy called about 30 minutes later stating that resident was standing at door, attempting to exit seek and would not leave door. This nurse was called to therapy and was unsuccessful in getting resident to leave door. The physician was called and a one time dose of Haldol (an atypical anti-psychotic medication) 5 mg (milligrams) was ordered. Call ALL RP (responsible parties) listed on face sheet and left message for return to call to notify of changes. Awaiting call back. Resident returned back to unit accompanied by Indigo UM (unit manager). Resident currently sitting in dining area eating snacks, will continue to monitor. -01/04/2017 4:15AM Pt (patient) sitting in room quietly. Tried to get ppd (a skin test for [DIAGNOSES REDACTED]) 2x and patient refused. -01/04/2017 12:17PM Rd (resident) in room with visitor. No c/o pain, no s/s (signs/symptoms) of discomfort or distress. Continue 15 minute checks. Wanderguard placed on rd (resident) right ankle. Call bell within reach. -01/04/2017 12:25PM PPD (purified protein derivative a skin test for [DIAGNOSES REDACTED]) given in right forearm. Lot 7 Exp (expiration) 1/9/17. Rd tolerated well. -01/05/2017 3:51AM Rsdt (resident) alert and oriented to self with confusion. Verbal with clear disoriented speech. Able to follow some commands and voice needs to staff. Rsdt took medications whole without difficulty. Ambulates independently. Rsdt roamed hallways and sat on sofa in TV area until assisted to bed at 1am. One attempt to exit side door this shift. Staff redirected without incident. Wander guard in place and functional. No c/o pain or discomfort. No combative behaviors. -01/05/2017 6:35PM Rd in room at present. No c/o pain, no s/s of discomfort or distress. Rd had some confusion earlier in shift. Rd pleasant at this time. Call bell within reach. -01/06/2017 4:27AM Rsdt alert and oriented to self with confusion. Verbal with clear speech. Does not respond appropriately to questions at times. Speech is confused. Rsdt does understand rested in bed until 9pm. Rsdt took medications whole. Up to chair in day room watching TV at this time. PO fluids and snack provided. Tolerated well. Incontinent episodes occurring this shift. Staff assisted with incontinent care dressing and grooming this shift. Two attempts to exit side doors this shift. Staff was able to easily redirected rsdt without incident. Wander guard is in place and functional. No behaviors noted thus far. No c/o pain or discomfort. PPD read this shift. Negative results. -01/06/2017 6:01PM Resident sitting in bedroom eating dinner. No behaviors noted. Resident had periods throughout day where he sat on the floor in front o (sic) the door looking out the window. No attempts to exit seek. Family in to visit with resident. Denies any type of pain, will continue to monitor. -01/07/2017 8:35AM Rsdt rested in bed until 12am. Rsdt initially refused medications while resting in bed stating not right now. Rsdt took medications after rsdt woke up and got out of bed at midnight. Took medications whole. Rsdt then sat in dining room area. Snacks were provided for rsdt. Po fluids encouraged. Rsdt returned to bed at 4am. Rsdt incontinent this shift. Requiring staff assistance with ADLs. No exit seeking noted. No behaviors. No s/sx of pain. Call light in each. -01/09/2017 7:41AM Resident alert, verbally responsive, ambulates, confused, got agaitated (sic)during this shift, redirected, call DON (Director of Nursing) @0530, called MD (physician) @ 545, currently in bed with eyes opened, calm now. MD stated, will call back and take a look @ meds. Will continue to monitor. -01/09/2017 1:20PM Resident verbally and physically abusive with staff. Not easily redirected. Get (sic) irate and agitated when tries to redirect. Several attempts to exit seek from all doors to unit. Resident stood at door for over thirty minutes attempting to exit seek. Dr. (surname) ordered a one time dose of Haldol 5 mg IM (intramuscular). IM given at 1300 and resident presently sitting in dining area. RP/Sister (name) notified and aware of resident behaviors, will continue to monitor. -01/09/2017 4:13PM Resident went out of facility with sister/rp to pay bills. Resident pleasant and cooperative. Wander guard removed until return. -01/09/2017 5:45PM Resident returned back to facility at 1740 (5:40PM) with much resistance. This nurse and CNA (certified nurse aide) assisted resident back into facility. Resident sitting eating dinner at this time. Wander guard applied to left ankle, will continue to monitor. -01/09/2017 11:47PM Resident alert, verbally responsive with confusion, no pain or discomfort noted, no behaviors noted @ (at) this time, currently in bed with eyes closed, call light within reach. -01/10/2017 3:54AM Res was sitting on bed and roommate accused him of stealing something from him and started swinging. Res tried to hold his hands down and then hit roommate in the face. They were separated and are being monitored. Dr. was notified. -01/10/2017 4:25PM Res has been taking his hearing aides apart. Was encouraged to give to staff and res has refused. will continue to encourage. -01/11/2017 2:58PM Res has been calm this shift. Has not been exiting seeking at this time. Res has been in common area watching TV. Will continue to monitor. -01/12/2017 5:34AM Rsdt alert with confusion. Verbal with clear disorganized speech. Ambulates independently. Incontinent of bowel and bladder this shift. Incontinent care provided by staff q 2 hrs and prn. Rsdt took medications whole with thin liquids. Remained in room until 4am. Rsdt sat in dining room eating snack until 5am. Rsdt then returned to bed. No exit seeking or combative behaviors noted this shift. Call light in reach. -01/12/2017 4:53PM Res has been trying to wait by doors this shift to get out. Res gets very confused and has been in and out of other res rooms. Res has gotten agitated but not combative. Will continue to monitor for behaviors. -01/12/2017 11:56PM Resident alert with confusion. Ambulates independently. Exit seeking behavior noted. Able to be redirected away from the door with much coaxing. Took all the evening meds whole with no difficulty or refusal. Wanders around the unit aimlessly. Going in and out of other resident's rooms. Staff have to continuously redirect him out of the rooms. Snacks and one on provided with ineffective results. Resident continues with the behaviors. -01/13/2017 12:36AM Body Audit Note: Resident alert with confusion. Transfers self and ambulates independently. Has exit seeking behaviors. One assist with bathing, dressing, and grooming. Continent of bowel and bladder with incontinent episodes at times. Feeds self with tray set up. Po intake adequate. Takes all meds whole. Scalp free of dandruff. Lesions to face. Oral mucosa moist. Hard of hearing. No redness to chest. Old scars noted on back and left outer arm. All knuckles on both hands calloused. Treatment in place to apply petroleum jelly q shift in place. Toenails thick. Denies pain -01/13/2017 3:34AM Resident found in room 307 urinating in the trash can. Aide cleaned up the mess and escorted resident out of room with no issues. -01/14/2017 3:50AM Reisdent (sic) restless. Stays up all night. Wanders around the unit aimlessly. Goes in and out of other resident's rooms and rummages through their belongings. Took out his private part and peed on the dining room floor. No exit seeking behavior thus far. -01/14/2017 3:35PM pt alert, plesantly (sic) confused throughout the shift. took meds without issues. easily redirected. no aggressiveness noted. no exit seeking noted. needs attended. safety maintained. will continue to monitor -01/14/2017 10:51PM Resident was sitting up in dining area having confused conversation with self. Yelling and arguing with people who aren't there. Wanders up and down the hallways into other resident's rooms. Resident from 320B was yelling out because resident was in his room refusing to get out. Resident became combative with staff when trying to redirect out of the room. Grabbed the spare bed and began shaking it. After much coaxing, aide was able to get resident out of the room. -01/15/2017 5:29AM Resident had door barricaded with two trashcans and wash basin. Drawers laying on the floor and the closet doors open. Resident was sitting on the bed talking to himself. -01/15/2017 11:33AM pt (patient) confused but pleasant. easily redirected. pt attempted to get out of exit door, alarm goes several times already since this morning. redirected away from exit doors. offered drinks and snacks. encouraged to watch TV and sit down. needs attended. no violent behaviors noted thus far. will continue to monitor -01/15/2017 6:40PM family brought pt one piece of hearing aid also a charger for the hearing aid -01/15/2017 10:05PM Door alarm sounding. Resident made an elopement attempt and succeeded in getting out of the building. Aide ran down the down hall to try and stop him before he could get out but didn't make it in time. Resident made it to the grass in front of the carport when the aide caught him. Resident brought back inside building. Resident talking and arguing with people who are not there. Refusing to sit down. Wandering around the unit cackling out loud. Goes in and out of resident's rooms. Refused evening meds x3 attempts. Kept pushing this nurse's hand away. Refused to have his hearing aid removed. Put his hand over his ear and told this nurse to get the hell away from him. Unable to be redirected. Snacks and one on one ineffective. ADON (Assistant Director of Nursing) notified of incident. On call MD (medical doctor) notified about resident's behaviors and unable to be redirected. Order to give Haldol 2mg IM one time. IM injection given in right deltoid. -01/15/2017 10:54PM RP notified. Refused VS (vital signs). -01/16/2017 12:57PM Haldol 2mg IM somewhat effective. Sitting up in dining area, resident continued to talk to people who were not there. Would nod out for brief periods then wake up and begin having conversations with self. No further exit seeking attempts. -01/16/2017 5:32AM Resident restless. Sits for only brief periods then up wandering around the unit. Goes in and out of other resident's rooms. Urinated on the floor near room 301. With much coaxing, resident came back into dining area and sat down. -01/17/2017 1:52AM At aprox (approximately) 7:00pm, (on the 16th) res noted in another res room with door closed.Staff (sic) unable to maintain access into room.Res (sic) blocking door with res body.Much (sic) emotional support and encouragement provided with effective results.Res (sic) up wandering in and out of other res rooms.Pushes (sic) on exit doors in attempt to exit building.Res (sic)refused all HS (bedtime) meds.Res (sic) running from N/A in dining area at aprox 10:00pm, (on the 16th) feet got tangled within each other and res fell to floor.Res (sic) fall wittnessed.Res (sic) did not hit head.Full ROM.No (sic)visible signs injury noted.Head (sic) to toe asses done.Vitals (sic) taken and within normal limits.Res (sic) assisted into chair in dining room.Res (sic) sat for a few moments,got (sic) back up and proceded (sic) to wander aimlessly.Res (sic) sister,(R/P),notified and aware of res uncooperativeness,unable (sic) to redirect,refusal (sic) of medication,and fall.Will (sic) refer res to P/T to eval (evaluate) and tx (treatment).MD (sic) notified via MD book.Res (sic) resting quietly in bed at this time.No (sic) distress noted. -01/17/2017 5:21AM MD notified, N.O. (new order) to send out to ER for eval (evaluation). -01/17/2017 7:41AM Res arose at aprox (approximately) 5:00am.Res (sic)noted in another res room turning over all W/Cs (sic) (wheelchairs),urinating on floor and breaking blinds on windows.Res (sic) assisted back to res room and into bed.At (sic) aprox 5:10am res in bed resting quietly.At (sic) aprox 5:11am,nurse rechecked res to discover res opened res room window and climbed out window.Nurse (sic) alerted staff.Nurse (sic) exited building out back door by res room.Res (sic) noted running down walkway at back of building.Res (sic) ran off nursing facility property onto street.Nurse (sic) caught res after aproximatly (sic) mile chase.Res (sic) became combative with nurse when nurse attempted to coax res back to building.Young (sic) man walking down street came and assisted nurse to calm res down by telling res we needed to go back to building to smoke D/T (due to) res requesting to smoke.N/A (sic) (nurse aide) pulled up in car,encouraged (sic) res to get in car.Nurse (sic) assisted res into n/a car without incident.Res (sic) assisted back into facility without incident.Unit (sic) manager,ADON,DON,and (sic)administrator notified of elopement.Nurse (sic) instructed to send res to ER for eval and TX.Squad (sic) notified of need for res transport.Sister (sic) notified and aware of elopement.Res (sic) transported to ER per squad at aprox 6:00am Observation of open resident room windows on 3/29/2017 prompted a tour with Maintenance Employee (ME) 14 of the hall where R138 had resided on 1/17/17. The window in the room previously occupied by R138's opened to a screen area of 22 height x 29 width (measuring tape was read by ME14); room 304, which was located at the other end of the hall, opened to a height of 23.5 inches. At 8:40 a.m., ME14 stated the windows on the hall may not all be identical in size like we just saw they opened to different heights, but they are all the same style and they all go up. In an interview on 3/29/17 at 5:15 p.m., the Maintenance Director, after ruling out windows that would egress to a secure area, stated there were 122 windows that would open to an unsafe area. In an interview on 3/29/17 at 1:28 p.m. the Administrator stated R138 was transferred out and not accepted back as the facility could not meet his needs and there were no other residents like that (R138) in the building. R138 was admitted to the hospital with [REDACTED]. The Resident was discharged from the hospital on [DATE] to home with family with a referral to Georgetown Mental Health and to see his family physician. 2) A review of R132's Resident Face Sheet revealed an admittance date to the facility of 4/28/16 and a re-admittance date of 11/19/16, with medical [DIAGNOSES REDACTED]. A review of R132's care plan revealed a problem of: Category: Behavioral Symptoms Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Resident often times goes to the unit door, pushes down on the door in hopes it may open. Staff attempts to re-direct her away from the door with food, activities, etc. Problem Start Date: 05/01/2016 Edited: 02/24/2017. The goal of the care plan was Resident will wander safely within specified boundaries. Edited: 01/23/2017. The approach to attain the goal was: Remove resident from other resident's rooms and unsafe conditions. Created 06/28/2016. In an interview on 3/30/17 at 3:20 p.m. the DON stated she felt the above care plan was for exit seeking and that was the only approach for the problem. Another page of R132's care plan listed a problem of: Category: Behavioral Symptoms Resident wanders around unit, at times needs redirection out of other rooms, attempts to void in inappropriate places/trash cans, prefers to sleep on couch in main area at times. Wanderguard in place. Problem Start Date: 05/05/2016 Edited: 03/28/17. The goal of the plan was Resident will wander safely without any negative outcomes from wandering. Approaches, all starting and created on 05/05/16, to attain the goal were: -Approach from the front. Walk in step with resident first before redirecting. -Provide activities based on prior lifestyle/interests: folding towels (specify). -Remove resident from other resident's rooms and unsafe situations. -When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.) A review of R132's Progress Notes revealed the following selected entries: -01/23/2017 2:22PM Resident up and combative with staff. Redirection with snacks and conversation attempted, unsuccessful. IM Ativan given to left deltoid. Resident running up and down halls at this time -01/25/2017 3:40AM Rsdt ambulating independently. Wandering in and out of other rsdt's rooms. Difficult to redirect. Attempting to remove clothing. Exit seeking. At 7:30 rsdt noted running down hallway with pants around anlkles(sic). Rsdt given prn (as needed) Klonopin (a benzodiazepine medication) with effective results. Rsdt resting comfortably in bed at this time. Call light in reach. -01/30/2017 6:30AM Resident took evening meds with much coaxing. Went into other residents rooms. Easily redirected out. Had no combative or exit seeking behaviors. Slept throughout out the night. Denies pain -02/01/2017 4:36PM Rd (resident) in day room at present. No c/o pain, no s/s of discomfort or distress. Rd removed from room 323 when witnessed with pants down over trashcan. Redirected to own bathroom in room. Redirected from several other rooms this shift. No combativeness noted. -02/05/2017 6:41PM pt attempted to exit doors several times today. alarm doors went off, staff was able to reach the exit door before 15s automatic door open. pt (patient) hard to redirect. will continue to monitor -02/07/2017 6:48PM At approximately 1715 (5:15 p.m.), rd observed chasing a staff member out of room 302. Rd was very agitated. As this nurse was approaching rd, the rp (responsible party) for room 304 approached rd to talk to her. Rd grabbed the visitor by the jacket and arm. This nurse approached rd and loosened hands off of visitor. Visitor states she is ok, but her chest and arm are sore and that she is going to have to rub them tonight. No injury observed to visitor. MD and RP notified. Rd is calm at this time -02/08/2017 4:10AM Resident became combative towards the CNA during care. After about 10 minutes, the resident had calm down and allowed the staff to provide care. -02/09/2017 6:17PM Resting in chair. Med pass tolerated. Res. entered hallway with just breif (sic) and shirt. Redireted(sic) easily. Wandering into others rooms.Toilete (sic) and offered snacks with were uneffective (sic) interventions. Attempting to exit through doors x 6 by holdign (sic) until alram (sic)sounds. When redirected from one will briskly walk to other end of corridor to try the other exit. No complaints of pain. No s/s od ditress (sic). Call light in reach. -02/10/2017 Resting in bed and call light in reach. While awake resident was ambulating down the hallways and wandering from room to room. No combativeness or taking off clothes. Cooperative and pleasant with the staff. -02/10/2017 6:39PM At approximately 1800, called to room 300 r/t rd in 300A tried to push this rd out of her room and this rd scratched the back of both hands on the rd. Rd easily redirected to day room. No apparent injury noted. Other rd would try to approach this rd and talk with her demanding to know why she scratched her. MD and RP notified. Will continue to monitor. -02/11/2017 4:29PM Rd is walking aroung (sic) the unit. No c/o pain, no s/s of discomfort or distress. No behaviors or combativeness noted. Rd has had several attempts to exit seek, but is easily redirected. Will continue to monitor. -02/13/2017 3:11PM Res tried taking clothes off x2 today. Res was toileted and quit disrobing. Res can get agitated quickly and is hard to redirect at times. will continue to monitor her behaviors. -02/17/2017 1:18AM Resident alert with confusion noted. Found resident in another resident room, redirected resident to dayroom. Tolerated meds crushed in applesauce without differculty (sic). No behavior issues or combativeness noted. Will continue to monitor. -02/17/2017 11:02PM Resident had exit seeking behaviors. Difficult to redirect. One on one and snack provided ineffective. PRN Klonopin 0.5 mg given at 2003. Had no combative behaviors or refusals of care. Resting quietly in bed at present time. -02/19/2017 6:50PM pt attempted to get out of the door exit today several times. door alarm goes off several times. made sure Wanderguard is on. Pty (sic) redirected away from door exit. easily redirected. no aggressiveness noted. offered fluids and food and encouraged to rest. needs attended. will continue to monitor -02/25/2017 7:41PM Rd was running hall and ran into room 321 and hit head on bathroom door. 1 cm (centimeter) laceration above left eye. Steri strips applied. New order to monitor steri strips for s/s of infection q (every) shift. PT (physical therapy) referral done. Neuro checks started. No other apparent injury noted. MD and RP notified. -02/25/2017 10:25PM Resident running around the unit. Gait unsteady. Attempts to exit seek x3. Going in other resident's rooms and rummaging through their drawers. Difficult to redirect. One on one ineffective. Resident unable to sit still. Prn (as needed) Klonopin 0.5 mg given at 1908 (7:08 p.m.) with positive effects. Resident is resting quietly in bed at present time. -03/03/2017 4:26PM At 1515, rd was running in the day room towards the nurses desk and tripped over the wheel of another rd's wheelchair. Rd did not hit her head. Head to toe assessment and ROM done with no apparent injury. Rd denies pain. Rd refuses to wear safety helmet and is not a good candidate for therapy r/t not able to follow commands. Will encourage rd to rest more. MD and RP notified. -03/04/2017 Resident pushing on the door handle x2. Easily redirected away from the door both times. No combative behaviors. No refusals of care or meds. Resting quietly in bed at present time. -03/06/2017 5:33PM Rd is walking the halls. No c/o pain, no s/s of discomfort or distress. Rd refuses to wear safety helmet. Rd is wearing elbow and knee pads as tolerated. No combativeness noted. Steri strips in place with no s/s of infection noted. Several attempts to exit seek this shift. -03/13/2017 12:08AM Residenr (sic) made several exit seeking attempts. Redirected away from the door each time. Running up and down the hallway. Going in and out of resident's rooms. Was found defecating on the floor in 312. Non-compliant with wearing safety helmet. Prn Klomopin (sic) 0.5 mg given at 1929 for increased anxiety. Positive effects. Resting quietly in bed at present time. -03/16/2017 8:01AM Rsdt is alert and oriented to self with confusion. Verbal with clear disorganized speech. Responds to simple questions. Staff anticipates needs. Ambulates independently. Rsdt roaming unit. Exit seeking. Delusions and increased agitation noted. Reported to this nurse by N/A that rsdt had become combative with care that shift. Prn Fluphenazine 2.5mg given at 8:38pm with little effect. At 9pm this nurse heard yelling in rsdtâ??s (sic) room. This nurse entered rsdt's room to note roommate sitting on floor yelling. Rsdt standing close by. Rsdtâ??s (sic) roommate stated I was going to come out of the room and come down to the dining room when she came behind me and pushed me down. This nurse asked rsdt â?? (sic) Did you push her down?â?? (sic) Rsdt began to rummage through roommateâ??s (sic) things mumbling â??(sic) church peopleâ?? (sic) and â?? (sic) I need to leave.â?? (sic) Rsdt did not respond to question directly. Rsdts were separated. Roommate requested to come into dining area to watch TV. Rsdt remained in room with CNA. Notified DON at 9:16pm. ADON notified at 9:18pm. Called and left VM for MD to return call at 9:20pm. Call to notify RP at 9:21pm. RP did not answer. Left VM to return call ASAP. Awaiting return call at this time. Prn Klonopin 0.5mg given for increased anxiety and combative behaviors. Effective results. 1:1 provided by CNA until rsdt fell asleep and was resting quietly in bed. Roommate returned to room at that time. Will continue to monitor frequently. -03/16/2017 3:45PM 3:15pm Resident refused incontinence care x 2 attempts. Resident becoming agitated (sic) and pacing back and forth in hallway. Rummaging through items. Staff offered fluids. Resident went to sit in dining room chair and sat down, tipping chair over in dining room. Witnessed per nurse. Resident did not hit head. Denies pain. Able to move extremities without difficulty. Staff provided one on one care, PRN Klonipin (sic) given for agitation (sic). Dr (surname) notified via phone of fall and VM left with RP (name). -03/19/2017 7:28PM Resting in chair. Med admin tolerated well. Appetite adequate when fed at 100%. Attempt yo (sic) exit building by pushing on door. Punched CNA in ab (abdomen) when redirected from open exit. No futher (sic) attempts. Wanderguard in place and functional. Safety maintained (sic). -03/20/2017 Resident had two exit seeking attempts. Going to the door and pushing on the handle. Redirected away from the door each time. No combative behaviors noted. Took all evening meds crushed in applesauce with much encouragement. No refusals of care. Asleep at present time. -03/24/2017 11:50PM Resident running around the unit. Going to the doors and pushing on the handle setting off the alarm. Reidrected (sic) away from the door each time. Continued with the behavior. Prn Klonopin 0.5 mg given at 1922 with positive results. Resident took all evening meds crushed with much encouragement. No combative behaviors or refusals of care. Resting quietly in bed at present time. -03/25/2017 4:54PM Rd sitting in day room. No c/o pain, no s/s of discomfort or distress. Rd has attempted to climb on tables several times this shift. Rd easily redirected. No combativeness noted. Rd refuses to wear helmet. -03/26/2017 5:48AM Resident went to the door x1. No combative behaviors. Took all evening meds crushed in applesauce. Slept throughout the night. No s/s of pain -03/28/2017 5:43PM Res ambulating around unit ad lib. Res has been exiting seeking and gets agitated quickly. Res can be redirected although is difficult at times.Res (sic) will not wear knee pads or helmet. On 3/29/17 at 11:18 a.m. the Administrator provided a list of residents that were using Wander guards. R132 was on the list of 19 residents. In an interview on 3/30/17 at 10:05 a.m., Licensed Practical Nurse (LPN)11 stated R132 could ambulate - she's fast/quick - she can run. When asked if LPN11 thought R132 could open a window, LPN11 responded Yeah, I would say she could, but if she hears an alarm she backs off. In a meeting on 3/29/17 at 3:20 p.m. between the Administrator, DON, Clinical Consultant, and Survey Team the facility was notified of

Based on record review and interview, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest physical and psychosocial well-being. Resident #1 was noted to have increased behavior problems and recommendations by the psychiatry nurse practitioner were not implemented. The psychiatry progress notes dated 10/12/15 recommended to restart [MEDICATION NAME] to 25 milligrams daily to address depression and anxiety; this recommendation was not followed up. One of three residents reviewed for behaviors. The facility also failed to implement an antibiotic timely. The findings included: Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Progress Note dated 10/1/15 at 1:28 AM revealed During walking rounds found resident in bed, visibly distressed. Shouting, 'untangle me . untangle me .' Pulled back covers to find resident wrapped tightly in (his/her) sheets. Unwrapped resident and tried to redirect by speaking in low calm voice. Attempts unsuccessful to redirect. Resident continued to yell out, shaking noted and resident asking for staff to not leave (him/her) alone. Scheduled [MEDICATION NAME] given along with other HS (hours of sleep) meds, with somewhat positive effects noted. This nurse sat at the bedside of the resident in attempts to keep the resident calm. Resident did become more quite, but agitation remains. PRN (as needed) [MEDICATION NAME] given at 1800 and 0130, rd (resident) stating that (s/he) is just miserable and hurts all over. Resident was able to find some broken sleep . Further review of the resident's Progress Notes revealed a Body Audit was completed on 10/1/15 at 1:38 PM. The body audit noted Resident #1 had 3 bruised to his/her left arm that were blue/reddish in color. Resident #1 also had 2 bruises on his/her right tibia that were blue/yellow in color and 2 areas of discoloration on the left tibia that were reddish in color and non blanchable. A small bluish bruise was noted on the inner left knee. Review of the resident's Body Audit dated 9/25/15 revealed the resident had a bruise on his/her right leg and also a bruise on his/her right arm and a bruise on the left arm. Further review of Resident #1's Nursing Progress Notes revealed on 10/10/15 the resident was yelling for help at shift change over. Resident found to have a high level of anxiety. Resident continually presses the call light, call light answered, immediately after exiting the room, call light pressed again. On 10/12/15 the resident was seen talking to people who were not in the room. On 10/14/15 Resident #1 was noted in bed at shift change with obvious signs of anxiety. The resident was talking fast, and jumping from topic to topic. Resident was pulling at his/her hair and when the nurse turned the resident to change brief found hair all about the bed. Resident stated that s/he was pulling his/her hair out. On 10/15/15 the resident was noted in bed during walking rounds in a high state of anxiety. The resident was calling out for help, asking for medications, yelling that his/her back hurt, side hurt etc. Resident didn't want the nurse to leave the room, each time the nurse attempted to leave the resident would give a reason to not leave. The resident was mashing the call light while the nurse was standing at the bedside providing care, the nurse asked the resident why s/he was mashing the call light while staff was in the room providing care and the resident stated s/he didn't know guessed it was a force of habit. Review of Resident #1's Psychiatry Progress Note dated 9/14/15 completed by the psychiatry nurse practitioner revealed the resident's anxiety level was becoming .increasingly uncontrollable at nights and his/her as needed [MEDICATION NAME] was not effective in calming him/her down. Patient yells out constantly for help, cries out. Paranoia noted in statements that people are going to do harm to her. Staff report s/he is extremely difficult to redirect . Recommendations included to taper and discontinue [MEDICATION NAME] related to no improvement. Review of the resident's Medications Administration History revealed [MEDICATION NAME] 10 mg (milligrams) three time a day was administered throughout the month of September and October. [MEDICATION NAME] was discontinued on 11/2/15. The Psychiatry Progress Note dated 10/12/15 completed by the Psychiatry Nurse Practitioner indicated the resident's chief complaint was anxiety, excessive worry, paranoia and confusion. Staff have noted patient to be tearful lately and cries in his/her room. Patient is worried about having to leave facility and states it is because s/he was rude to someone. Further review of the Psychiatry Progress Note dated 10/12/15 revealed no documentation related to Resident #1's allegation of mental abuse and the incident that occurred on 9/30/15. The Nurse Practitioner listed current psychiatric medications as [MEDICATION NAME] 10 milligrams daily for depression and [MEDICATION NAME] 1 milligram daily and as needed. The recommendations included to restart [MEDICATION NAME] to 25 milligrams daily to address depression and anxiety. Further review of Resident #1's Psychiatry Progress Notes revealed a 4/6/15 note that stated the reason for follow-up was noted as medication check. Recommendations included to continue medication as prescribed, the patient was stable at current dose and/or needs more time to see beneficial effects. Dose reduction attempted and/or reduction will cause decompensation of patient. Will consider dose reduction in [MEDICATION NAME] in the future due to multiple antidepressant treatment. Current psychiatric medications were listed as [MEDICATION NAME] 5 mg as needed for anxiety, [MEDICATION NAME] 10 mg TID for anxiety, [MEDICATION NAME] 10 mg for depression and [MEDICATION NAME] 50 mg for depression/sleep. Review of Resident #1's Physician's Telephone Orders revealed and order dated 4/20/15 to discontinue [MEDICATION NAME]. On 11/2/15 the Psychiatry Progress Note revealed the current psychiatric medications were listed as [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] 10 mg three times a day and [MEDICATION NAME] 1 mg daily and as needed. The psychiatry nurse practitioner evaluated Resident #1 per pharmacy consultation regarding a gradual dose reduction for [MEDICATION NAME]. The psychiatry nurse practitioner recommended to taper and discontinue [MEDICATION NAME] since no improvement was noted. Review of Resident #1's Physician's Telephone Orders revealed no order to restart the [MEDICATION NAME] 25 milligrams daily. Review of Resident #1's October 2015 and November 2015 Medication Administration Records revealed no order for [MEDICATION NAME] 25 milligrams (mg) daily. In an interview with the surveyor on 3/10/16 at approximately 5:45 PM, the facility administrator stated the psychiatry nurse practitioner enters his/her medication orders into the computer, the order goes into the resident's electronic medical record and is transmitted to the pharmacy. The Assistant Director of Nursing reviewed orders and was not able to locate an order for [REDACTED].>In a telephone interview with the surveyor on 3/25/16 at approximately 2:35 PM, the psychiatry nurse practitioner stated s/he is usually at the facility every week. The Psychiatry Nurse Practitioner stated s/he enters orders for medications into the computer. S/he confirmed that she did not see [MEDICATION NAME] listed on the resident's medication list in November 2015. The Psychiatry Nurse Practitioner stated s/he would have documented in the progress note if s/he had been told about Resident #1's allegation of mental abuse related to the incident of 9/30/15 . Review of Resident #1's Specimen Inquiry dated 10/6/15 revealed a preliminary urine culture result with gram negative rods that was verified at 8:02 on 10/7/15. At the bottom of the form was a note dated 10/7/15 for [MEDICATION NAME] 100 milligrams twice a day x 7 days. The note was signed by the nurse practitioner. Review of the Concerns from Unit (#1) form completed for Resident #1 dated 10/8/15 revealed the resident was continuously yelling out help, help, attention seeking behaviors, throwing remote call light to floor, being very demanding with staff. The nurse practitioner completed the form on 10/8/15 and commented that the resident was diagnosed with [REDACTED]. Review of the Prescription Order from for Resident #1 revealed [MEDICATION NAME] 100 milligrams twice a day x 7 days was entered on 10/9/15 at 4:48 PM. Review of Resident #1's Medication Administration History for October 2015 revealed [MEDICATION NAME] was started on 10/9/15 at the 9:00 PM medication administration. In an interview with the surveyor on 3/10/16 at approximately 5:45 PM, the Director of Nursing stated Resident #1 had a preliminary lab on 10/7/15 and was awaiting culture that came on 10/8/15. In a telephone interview with the surveyor on 3/16/16 at approximately 11:15 AM, the Nurse Practitioner stated s/he would expect the order for [MEDICATION NAME] to have started on 10/7/15. S/he signs the lab report and gives it to the Unit Manager or nurse and they enter the order for the medication. There is no set policy for how the orders are processed.

Based on record review and interview, the facility failed to implement written policies and procedures that prohibit abuse of residents. Resident #1 was found with his/her sheets tightly tucked around his/her body. Certified Nurse Aide (CNA) #1 admitted to tucking the resident so s/he could not get to his/her brief. CNA #1 continued to work after the incident was identified by two nurses. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to report the allegation of abuse timely to facility administration. One of one resident reviewed for allegation of abuse. The findings included: The facility submitted a reportable incident to the state survey agency on 10/1/15. The reportable was related to an allegation of mental abuse for Resident #1 by CNA #1 that occurred on 9/30/15. The reportable indicated Resident #1 was found in bed visibly distressed and shouting untangle me, untangle me. The resident was wrapped tightly in her/his sheets. The resident alleged that her/his CNA did it. Review of the facility's Summary Report of Facility Investigation dated 10/8/16 indicated the investigation revealed that Resident #1 was mentally abused by her/his assigned CNA (CNA #1) on the evening of 9/30/15. CNA #1 admitted to RN #1 and LPN #1 that s/he tucked Resident #1's sheet under him/her, but did not know that s/he could not do that. Resident #1, who is alert and oriented, told RN #1 and LPN #1 that CNA #1 was the one that wrapped me up. Resident #1 pleaded to RN #1 and LPN #1 that CNA #1 not do that again. The nurses reported that Resident #1 was anxious and agitated throughout this entire incident. RN #1 and LPN #1 failed to report the incident to their Supervisor/ Director of Nursing and/or the facility Administrator in a timely manner. The incident was observed on 9/30/15 at approximately 7:00 PM. RN #1 and LPN #1 did not report the incident until the next day, 10/1/15 at 7:00 AM. Resident #1 was noted to reside on Unit (#1) in the facility. Review of the Unit (#1) Assignment Sheet for 9/30/15 revealed CNA #1 worked the 3:00-11:00 PM shift and was assigned to Resident #1's room. CNA #1 had a notation that s/he would be on the Unit (#2) at 11:00 PM. Review of the Unit (#2) Daily Assignment Sheet dated 9/30/15 revealed CNA #1 worked the 11:00 PM - 7:00 AM shift. Neither sheet was updated to indicate there were any staffing changes. Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of the facility's Abuse & Neglect Prohibition Policy revealed the facility will protect residents from harm during the investigation of any alleged abuse. In an interview with surveyor on 3/10/16 at approximately 3:55 PM, the facility Administrator stated she was not at the facility at the time of incident. The Administrator stated staff is trained to notify the nursing administrator on call at the time of the event. They should have sent CNA #1 home immediately. As licensed nurses they are responsible for suspending immediately. The nurses did not follow policy or procedure. The DON called him/her to let her know about the incident at 7 AM the next morning on 10/1/15. The Administrator stated s/he talked with CNA #1 and s/he said s/he tucked Resident #1 in tight. CNA #1 stated s/he did not know that was considered a restraint. The facility Administrator stated CNA #1 worked on Magnolia until 11 PM and then went to [MEDICATION NAME] unit and worked until 3:06 AM. CNA #1 said s/he tucked the resident in tight because s/he was digging in his/her brief. The Administrator stated s/he did not know of any notification of the psychiatry nurse practitioner after incident and there was no documentation in the resident's computer medical chart.

Based on record review and interview, the facility failed to ensure each resident was free from mental abuse. Resident #1 was found with his/her sheets tightly tucked around his/her body. Certified Nurse Aide (CNA) #1 admitted to tucking the resident so s/he could not get to his/her brief. One of one resident reviewed for allegation of abuse. The findings included: The facility submitted a reportable incident to the state survey agency on 10/1/15. The reportable was related to an allegation of mental abuse for Resident #1 by CNA #1 that occurred on 9/30/15. The reportable indicated Resident #1 was found in bed visibly distressed and shouting untangle me, untangle me. The resident was wrapped tightly in his/her sheets. The resident alleged that his/her CNA did it. Review of the facility's Summary Report of Facility Investigation dated 10/8/16 indicated the investigation revealed that Resident #1 was mentally abused by his/her assigned CNA (CNA #1) on the evening of 9/30/15. CNA #1 admitted to Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 that s/he tucked Resident #1's sheet under him/her, but did not know that s/he could not do that. Resident #1, who is alert and oriented, told RN #1 and LPN #1 that CNA #1 was the one that wrapped me up. Resident #1 pleaded to RN #1 and LPN #1 that CNA #1 not do that again. The nurses reported that Resident #1 was anxious and agitated throughout the entire incident. RN #1 and LPN #1 failed to report the incident to their Supervisor/ Director of Nursing and/or the facility Administrator in a timely manner. The incident was observed on 9/30/15 at approximately 7:00 PM. RN #1 and LPN #1 did not report the incident until the next day, 10/1/15 at 7:00 AM. Resident #1 was noted to reside on the Unit (#1) in the facility. Review of the Unit (#1) Assignment Sheet for 9/30/15 revealed CNA #1 worked the 3:00-11:00 PM shift and was assigned to Resident #1's room. CNA #1 had a notation that s/he would be on the Unit (#2) at 11:00 PM. Review of the Unit (#2) Daily Assignment Sheet dated 9/30/15 revealed CNA #1 worked the 11:00 PM - 7:00 AM shift. Neither sheet was updated to indicate there were any staffing changes. Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Progress Note dated 10/1/15 at 1:28 AM revealed During walking rounds found resident in bed, visibly distressed. Shouting, 'untangle me . untangle me .' Pulled back covers to find resident wrapped tightly in (his/her) sheets. Unwrapped resident and tried to redirect by speaking in low calm voice. Attempts unsuccessful to redirect. Resident continued to yell out, shaking noted and resident asking for staff to not leave (him/her) alone. Scheduled [MEDICATION NAME] given along with other HS (hours of sleep) meds, with somewhat positive effects noted. This nurse sat at the bedside of the resident in attempts to keep the resident calm. Resident did become more quite, but agitation remains. PRN (as needed) [MEDICATION NAME] given at 1800 and 0130, rd (resident) stating that (s/he) is just miserable and hurts all over. Resident was able to find some broken sleep . Further review of the resident's Progress Notes revealed a Body Audit was completed on 10/1/15 at 1:38 PM. The body audit noted Resident #1 had 3 bruised to his/her left arm that were blue/reddish in color. Resident #1 also had 2 bruises on his/her right tibia that were blue/yellow in color and 2 areas of discoloration on the left tibia that were reddish in color and non blanchable. A small bluish bruise was noted on the inner left knee. Review of the resident's Body Audit dated 9/25/15 revealed the resident had a bruise on his/her right leg and also a bruise on his/her right arm and a bruise on the left arm. Review of the Time Card Report dated 9/30/15 revealed CNA #1 worked from 3:06 PM - 3:06 AM that day. Review of the facility's Abuse & Neglect Prohibition Policy revealed the facility will protect residents from harm during the investigation of any alleged abuse. Review of Resident #1's Psychiatry Progress Note dated 10/12/15 completed by the Psychiatry Nurse Practitioner indicated the resident's chief complaint was anxiety, excessive worry, paranoia and confusion. .Staff have noted patient to be tearful lately and cries in his/her room. Patient is worried about having to leave facility and states it is because s/he was rude to someone . Further review of the Psychiatry Progress Note dated 10/12/15 revealed no documentation related to Resident #1's allegation of mental abuse. The Nurse Practitioner listed current psychiatric medications as [MEDICATION NAME] 10 milligrams daily for depression and [MEDICATION NAME] 1 milligram daily and as needed. In an interview with the surveyor on 3/9/16 at approximately 7:15 PM, RN #1 stated s/he worked 7 PM-7 AM on 9/30/15. S/he was doing walking rounds with LPN #1. RN #1 stated Resident #1 was alert and oriented with some confusion. When they arrived at Resident #1's room s/he was saying I can't breathe, turning his/her head back and forth, and respirations were heightened. When s/he got to the bedside s/he noticed the resident had his/her arms by his/her side and the sheet was wrapped tightly around him/her and tucked underneath him/her. RN #1 and LPN #1 pulled the sheet to release the resident. RN #1 noticed the resident's brief was on backwards. Resident #1 was trapped and s/he felt trapped. The resident was saying s/he couldn't breathe. Resident #1 said they don't want me to dig in my poop. S/he would pull at his/her brief and would dig in his/her poop. RN #1 tried to comfort the resident and sat with him/her for 2.5 hours to calm him/her down. That was not something s/he normally had to do. CNA #1 was assigned to the resident on 9/30/15. Resident #1 was scared but did calm down, RN #1 gave him/her as needed anxiety medication to help calm him/her down. RN #1 and LPN #1 reported the incident to the Unit Manager the next morning at shift change. CNA #1 continued to work that night and RN #1 did not talk with the nurse on Unit (#2) to let him/her know about the incident with CNA #1. In an interview with the surveyor on 3/10/16 at approximately 9:35 AM, Director of Social Service stated s/he talked with Resident #1 on 10/1/15. The resident stated (s/he) tied me up. Resident #1 was more anxious than usual that day. Resident #1 was consistent in his/her story about what happened. In an interview with the surveyor on 3/10/16 at approximately 10:40 AM, LPN #1 stated s/he and the night nurse were doing rounds. They heard Resident #1 saying help me, help me. They went into his/her room and pulled the sheets back and his/her arms were pinned. Resident #1 said s/he did it, CNA #1 walked in the room behind them and the resident said s/he did. CNA #1 said I did it, I was stopping him/her from sticking his/her hands in his/her brief. LPN #1 told the CNA s/he couldn't do that and CNA #1 said s/he didn't know that and left out of the room. LPN #1 and RN #1 got the resident untucked and straightened sheets and left the room. There was one sheet over the tucked sheet so you couldn't see until removed. LPN #1 stated s/he could tell how the resident was positioned that s/he couldn't move his/her arms and that is when they removed the sheet. Resident #1 was very upset when they got to the room. The resident was still upset when they left but not as upset. LPN #1 contacted the Unit Manager the next morning and told him/her about the situation and asked if that was abuse. The Unit Manager said yes and s/he would follow up. In an interview with surveyor on 3/10/16 at approximately 3:55 PM, the facility Administrator stated s/he was not at the facility at the time of incident. The Administrator stated staff is trained to notify the nursing administrator on call at the time of the event. They should have sent CNA #1 home immediately. As licensed nurses they are responsible for suspending immediately. The nurses did not follow policy or procedure. The DON (director of nursing) called him/her to let her know about the incident at 7 AM the next morning on 10/1/15. The Administrator stated s/he talked with CNA #1 and s/he said s/he tucked Resident #1 in tight. CNA #1 stated s/he did not know that was considered a restraint. The facility Administrator stated CNA #1 worked on Unit (#1) until 11 PM and then went to Unit (#2) and worked until 3:06 AM. CNA #1 said s/he tucked the resident in tight because s/he was digging in his/her brief. The Administrator stated s/he did not know of any notification of the psychiatry nurse practitioner after incident and there was no documentation in the resident's computer medical chart. In an interview with the surveyor on 3/10/16 at approximately 5:45 PM, the facility administrator stated CNA #1 did not take care of Resident #1 after 7:00 PM. The facility administrator stated assignment sheets should be updated to reflect any staff change of who is providing care for residents.

On the day of the complaint inspection, based on record review, observations, interviews, and review of facility injury investigation files, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident who sustained injury from an improper transfer from bed to chair on 4/30/12 (#1). Certified Nursing Assistant (CNA) #1 used a manual assist of one person to transfer the resident from bed to wheelchair. The resident, however, needed mechanical lift with the assist of two persons for transfer. A statement from CNA #2 as part of the facility's investigation, revealed CNA #1 confused Resident #1 for her roommate, who was an assist of one person for transfer. The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instrument (assessment reference date of 10/23/11) and the latest quarterly Minimum Date Set (assessment reference date of 4/8/12) revealed the resident required the total assistance of two people for transfer from bed to chair. The annual assessment notes stated the resident needed the assist of two people with a mechanical lift for transfer. The quarterly assessment showed a BIMS (Brief Interview for Mental Status) score of 12/15, indicating moderate cognitive impairment Review of the medical record revealed the resident's drug regimen included the antiplatelet agent, Aggrenox, increasing the risk for bleeding. Review of the resident's plan of care revealed "Needs dependent assistance of 2 with hoyer (sic) (total mechanical lift) for transfers." The Kardex for nursing assistants also showed the resident needed mechanical lift for transfers. Review of the facility's policy for Resident Transfer: Mechanical Lift showed " ... Mechanical lifts require at least a 2-person assist. ..." The policy also stated under Training: "All staff should be in-serviced on use of a mechanical lift, and Demonstrate his/her competency with the device to his/her supervisor. ..." Review of the Nurse's Notes showed an entry on 4/30/12 at 0700 stating the resident complained of pain in her left shoulder and left knee after being put back to bed that morning. Review of the facility's injury report revealed the resident's left shoulder was swollen. The physician ordered portable x-rays which were negative for fracture. The resident filed a grievance report on 4/30/12 stating that the CNA (#1) that got her out of bed that morning hurt her left shoulder and her left heel. Resident #1 told the Social Worker that the CNA picked her up by the arm and put her in her wheelchair. She heard her arm crack and thought her shoulder was out of place. The resident also stated that in the process of the transfer, the CNA hit her heel on something on the wheelchair. Resident #1 said when she was put back to bed, the CNA slammed her hard on the bed. A Nurse's Note on 5/1/12 at 1630 said the resident had significant bruising to the anterior part of her left upper arm. There was bruising to the right chest spreading from the breast to under the axilla. Observation of the resident on 5/23/12 at 10:45 AM revealed she still showed evidence of extensive bruising. A large dark bruise extended down her left anterior/inner upper arm from axilla level to just above the elbow. Another large dark bruise was observed from the elbow to above the wrist on the left outer forearm. A round, dark bruise was noted on the left chest wall under the axilla. Approximately one half of the resident's right breast was darkly bruised. The resident complained of left arm pain and left knee pain when visited by the physician at 12:40 PM. The resident was unwilling to speak about the incident on the day of the complaint inspection. Review of the facility's investigative materials revealed a written statement from CNA #2, who was on duty 11-7 on 4/29-30/12. She said the resident was up in her wheelchair by the nurses' station early on 4/30/12. The resident wanted to go back to bed. She did not have the mechanical lift pad underneath her. CNA #2 assisted CNA #1 to put the resident back to bed using a 2 person lift. CNA #2 was on the resident's right side and CNA #1 was on the left. CNA #2 wrote in her statement that CNA #1 confused the two residents in the room, she thought Resident #1 was on her assignment but she should have attended the roommate instead of Resident #1. Review of the CNA Assignment Sheet for the 11-7 shift on 4/29-30/12 clearly showed CNA #1 was assigned to Resident #2 in the B bed, and not Resident #1 in the A bed. A written statement from the Unit Manager dated 4/30/12 said she called CNA #1 to ask if the CNA had assisted the resident out of bed that morning. CNA #1 responded "yes I sure did." CNA #1 declined to provide a written statement for the facility's file. Review of CNA #1's employee file failed to show evidence, per the facility's Resident Transfer: Mechanical Lift policy, that CNA #1 had been trained in using a mechanical lift and had completed a return demonstration showing competency.