**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #33 received adequate supervision to manage known aggressive behaviors towards other residents. This finding affected one (Resident #33) and had the potential to affect all 42 residents residing on the secured behavioral health unit. The facility census was 42. Findings include: Review of Resident #33's medical record revealed he was admitted on [DATE] with diagnoses including delusional disorders, impulse disorder, unspecified dementia, and auditory hallucinations. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited memory problems. Review of Resident #33's progress note dated 10/16/22 at 4:01 P.M. indicated he entered a common area and walked up behind a male peer and became physically aggressive. Both were separated immediately before further altercation could occur. Resident #33 indicated he was hearing voices and had a known history of becoming physically aggressive when he was feeling this way. Review of Resident #33's progress note dated 10/16/22 at 5:30 P.M. indicated a State Tested Nursing Assistant (STNA) reported that he approached a male peer and attempted to become physically aggressive with him. The male pushed Resident #33 back with open hands to avoid an altercation. He was asked to return to his room to self soothe and no injuries were noted. Review of Resident #33's progress note dated 10/18/22 at 1:24 P.M. indicated the nurse was informed by the STNA that Resident #33 struck another resident with a closed fist in the jaw while they were outside at the smoke break. He was sent to his room to self-soothe. Review of Resident #33's progress note dated 10/18/22 at 4:20 P.M. indicated the resident's roommate approached the nursing station and reported that Resident #33 attempted to become physically aggressive with him for unprovoked reasons in their room. One to one observation was attempted but ineffective and oral Ativan (anti-anxiety medication) was offered and accepted. The roommate was moved to another room to avoid further interactions. Review of Resident #33's progress note dated 10/28/22 at 2:36 P.M. indicated he became physical with another resident and had three lacerations around the left eye due to the physical altercation. The superior eye laceration measured 0.2 cm (centimeters) by 0.7 cm; a laceration near the corner of the outer eye measured 0.2 cm by 1.0 cm and the left cheek laceration measured 0.2 cm by 0.5 cm. He had a bruise under the left eye. Redirection and one to one were ineffective and an as needed medication was administered per order. Review of Resident #33's progress note dated 10/28/22 at 3:00 P.M. indicated he started kicking another male resident who was lying on the floor. He was redirected away and to sit back on the bench in line of sight of nursing. He again got up and became physical with another male resident (resulting in two scratch marks to his right outer eye area which measured 0.2 cm by 2 cm by 5 cm). He sat down again and when another male resident came to the nursing room door, he became physical with him (resulting in a scratch to the right cheek which measured 0.3 cm by 0.5 cm). Redirection and one to one were ineffective. Review of Resident #33's progress note dated 11/01/22 at 4:33 P.M. indicated he approached another male in the common area and became physically aggressive, attempting to strike the peer. He was redirected to his room to decrease environmental stimuli and an as needed medication was administered per order. Review of Resident #33's progress note dated 11/03/22 at 5:03 P.M. indicated the STNA reported that he approached another male peer in the dining room and attempted to become physically aggressive. They were separated before injuries could occur. He was sent to his room to self-soothe and placed on a behavior plan per the facility policy. Review of Resident #33's progress note dated 11/08/22 at 7:45 P.M. indicated he was in the lobby and became physically aggressive with a male peer. He was redirected and was assisted back to his bedroom to self soothe. Review of Resident #33's progress note dated 11/10/22 at 10:58 A.M. indicated he was physical with another peer while standing in the drink line. He stated he was hearing voices. He lost smoking privileges and only water and house snacks for the next 24 hours. Review of Resident #33's progress note dated 11/12/22 at 8:10 P.M. indicated he was on the 300-hall returning from a smoke break when he became physically aggressive with a male peer. The residents were separated before injury could occur and he was sent to his room to self soothe. Review of Resident #33's progress note dated 11/17/22 at 7:56 P.M. indicated he was in the smoke line when he turned to a male peer and became physically aggressive. He stated he was hearing voices and a behavior plan was initiated per the facility policy. Review of Resident #33's progress note dated 11/20/22 at 8:00 P.M. indicated he became physically aggressive with another male resident, striking him with a closed fist. The resident retaliated and struck Resident #33 causing him to lose his balance and he fell to the floor, striking his head. A laceration was noted to the back of his head and first aid was attempted by the nursing staff. The emergency squad was notified, the physician was called, the Director of Nursing (DON) was called, and an attempt was made to contact the guardian. Refer to F600. Review of Resident #33's progress note dated 11/24/22 at 5:35 P.M. indicated he was physically aggressive with a peer in the dining room. Both residents were separated, and no injuries were noted. Redirection and one to one were ineffective. Review of Resident #33's Psychiatrist Follow-Up Monthly Progress Note dated 11/26/22 revealed he continued to have aggressive episodes. He was hospitalized with a laceration of his head. He was in his room most of the time. Interview on 11/28/22 at 9:50 A.M. with the DON indicated Resident #33 heard voices. The DON stated the facility had 100% (percent) behavioral residents. She indicated Resident #33's voices tell him to hurt people and they do the best they can with behavioral modification and medication management. They also try to avoid having Resident #33 stand in lines, separate during smoke breaks and during meals. She stated Resident #33 was seen by a psychiatrist to adjust his medications, but he was not sent out to the hospital for a psychiatric evaluation following the incident on 11/20/22 because he was not appropriate to be admitted . She stated he was sent to the hospital for the laceration on the back of his head. Telephone interview on 11/28/22 at 11:30 A.M. with Physician #804 stated Resident #33 would hear a commanding voice and then act upon the voice; it was part of his diagnoses of schizophrenia. Interview on 11/28/22 at 2:11 P.M. with Psychiatrist #805 indicated he had assessed Resident #33 recently and ordered bloodwork. This deficiency substantiates Complaint Number OH00137774.

Based on record review and staff interview the facility failed to ensure advance directives matched in the electronic health record and paper medical record. This affected one resident (#9) of 18 residents reviewed for advance directives. Findings include: Review of Resident #9's medical record revealed an admission date of 06/20/13 with admission diagnoses that included diabetes mellitus, dementia with behaviors, paranoid schizophrenia and bipolar disorder. Review of the electronic health record revealed a physician's order, dated 02/02/21 which indicated Resident #9's advance directive (code status) was a Do Not Resuscitate Comfort Care - Arrest (DNRCC-A). Further review of the EHR also revealed the resident information code status indicated DNRCC-A. Review of the hard chart/paper medical record included a resident face sheet which indicated a code status of Full Code. Further review of the paper medical record found no evidence of advance directives or a DNR form which indicated a DNRCC-A code status was in place. Interview with the Director of Nursing (DON) on 10/12/22 at 8:45 A.M. verified the electronic health record and hard chart/paper medical record for the resident did not match. The DON revealed the hard chart should have indicated Resident #9 was a DNRCC-A and also contain the physician and resident representative signed DNRCC-A form.

Based on record review and interview the facility failed to ensure pharmacy recommendations were complete and provided rationale for the continued use or psychoactive medications (with or without gradual dose reductions) for Resident #19. This affected one resident (#19) of five residents reviewed for unnecessary medication use. Finding include: Record review revealed Resident #19 was admitted to this facility on 08/14/20 with admitting diagnoses including type II diabetes, cellulitis of right lower limb, open wound of right great toe, repeated falls, heart failure, post traumatic seizures, depressive disorder and schizoaffective disorder. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/30/22 revealed the resident had severe cognitive impairment, required extensive assistance from one staff for dressing and supervision from one staff for bed mobility, transfers, toilet use and personal hygiene. The MDS assessment revealed the resident received anti-psychotic, anti-anxiety and anti-depressant medications during the assessment reference period. Review of the pharmacy review and monitoring for Resident #19 revealed on 02/16/22 and 08/07/22 the pharmacy sent a gradual dose reduction letter to Resident #19's physician. The letter on 02/16/22 noted the resident received the following psychoactive medications: - Clozapine 50 milligrams (mg) daily - Clozapine 100 mg two tablets at bed time - Clonazepam 1 mg three times a day - Trazodone 100 mg at bedtime - Haldol 5 mg give one and one half tablet (7.5 mg) two times a day - Haldol 5 mg every 6 hours as needed for agitation - Haldol 5 mg/ml give every 6 hours intramuscularly as needed for agitation - Vibryd 40 mg daily - Duloxetine 60 mg daily The recommendation revealed to please update the facility psychoactive medication documentation by completing the information requested. However, nothing was filled out to show if a gradual dose reduction was clinically indicated or contraindicated. There was no rational listed as to why dose reductions would be indicated or contraindicated. The physician only signed his name to the form. The pharmacy recommendation, dated 08/07/22 was almost a duplicate copy of the 02/16/22 notice with the exception of two additional medications added (Prazosin 3 mg at bedtime and Prazosin 2 mg at bedtime; not to exceed 3 mg). There was no evidence the physician addressed the recommendation to provide evidence as to whether a a gradual dose reduction was indicated or contraindicated. There was no rationale included indicating why the dose reductions were indicated or contraindicated. Again, the physician just signed his name to the form. Interview with the Director of Nursing on 10/13/22 at 8:15 A.M. verified the above findings and verified his documentation as well as the psychiatrist documentation did not address whether gradual dose reductions were indicated or contraindicated at the time of the pharmacist review in 02/2022 and 08/2022.

Based on observations, interviews and record review, the facility failed to ensure the smoking area held ashtrays for disposal of ashes and failed to maintain a clean environment free of cigarette butts. This affected twenty-four (Resident #28, #19, #31, #39, #33, #8, #42, #15, #1, #24, #27, #29, #30, #18, #38, #36, #40, #22, #20, #32, #14, #9, #3 and #34) of thirty-two residents who smoke. Findings include: An observation on 09/30/19 at 3:08 P.M. of the smoking area revealed there were twenty-four residents (Resident #28, #19, #31, #39, #33, #8, #42, #15, #1, #24, #27, #29, #30, #18, #38, #36, #40, #22, #20, #32, #14, #9, #3 and #34) smoking in the outdoor designated area. There were two metal pails with lids in the area, one was in the center of the outdoor canopied space with twelve surrounding small benches placed in a square. Each bench was approximately four feet from the metal pail. The other pail was near the entrance door on the right side of the door as you would exit. There were no ashtrays present in this designated smoking area. The pails were used to dispose of used cigarette butts. There were nineteen residents on the benches and five residents sitting on the concrete ground of the area leaning against the fence. The fence was a chain link, and there was grass surrounding the enclosed area for smoking. All twenty-four residents dropped their cigarette ashes to the concrete ground near them. Two residents (Resident #42 and Resident #20)flicked their ashes through the chain link fence to the outside grassy area. There were used cigarette butts just outside of the fenced area around the smoking space on all sides of the enclosure and there were approximately 60 to 100 used butts under the benches and on the concrete floor. The two metal pails were each half full of cigarette butts. This was verified by State Tested Nursing Assistant (STNA) #118 who revealed they would usually clean up the area after each break. There were eight cigarette breaks each day. During this cigarette break, neither STNA who had supervised smoking reminded residents to use the pails and not the ground or floor area for ashes. An interview on 09/30/19 at 3:29 P.M. with STNA #118 revealed during each cigarette break, each resident was given one cigarette only and they were supervised by two STNAs. All residents required some level of supervision for smoking. An interview and observation on 10/02/19 at 10:06 A.M. of the smoking area with Maintenance Supervisor #155 revealed and confirmed there were no ashtrays in the smoking area. He agreed there were ash marks on the concrete and fifteen cigarette butts still on the ground. An interview on 10/02/19 at 10:11 A.M. with Licensed Practical Nurse (LPN) #101 revealed the STNAs were supposed to pick up cigarette butts at the end of each shift. She had no information regarding ash trays. A record review of the smoking policy, revised December 2017, revealed the facility should establish and maintain safe smoking practices. The policy stated, ashtrays are emptied into designated receptacles.