Every finding on record at Kingwood Healthcare Center

Based on record review, observation and staff interviews, the facility failed to ensure a safe and sanitary environment was provided to prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #3, #111. Facility Census: 116. a) Resident #111 On 05/11/26 at 11:19 AM, during an interview with Resident # 111, staff observed a hole in the bottom edge of his walker seat's plastic cover, exposing the inner padding. During a facility walkthrough with the Assistant Director of Nursing (ADON), on 05/12/26 at 1:55 PM, she acknowledged Resident #111's walker seat with the hole and exposed inner padding and stated she would report it so the seat cover could be repaired. b) On 05/11/2026 at around 2:15 PM the surveyor observed two resident ice packs with names on them in the freezer in the nourishment room on the 300 hall. The surveyor also observed residents' personal food items (ice cream, frozen foods) in the freezer. A reminder notice hanging on the side of the freezer stated, Do not place residents' ice packs in the nutrition station freezer. They may be placed in the small one, just inside the door, in therapy. Licensed Practical Nurse (95) verified these items should not be in there, reporting, I will remind the nursing assistants to keep these in the therapy room. c) During an initial walkthrough of the facility on 05/11/26 at 11:30 AM the surveyor identified the following infection control concerns: Two (2) sit to stand lifts on the 200 hallway both had a transfer sling still attached. The surveyor asked Nurse Assistant (NA) #109 if transfer slings were allowed to be stored on the sit-to-stand lifts in the hallway when not in use, and she stated, No, we have a storage location for them. The surveyor also asked Licensed Practical Nurse (LPN) #56 if transfer slings were allowed to be stored on the sit-to-stand lifts in the hallway when not in use, and she stated I am not sure, I will find out for you. d) On 05/11/26 at 11:40 AM one (1) Geri chair located on 100 hallway was soiled with food debris. One (1) wheel chair located on the 100 hallway was soiled with debris. One (1) wheelchair located on the 100 hallway had a seat that had a tear in the fabric and would not be easily cleanable. e) Observation on 05/11/26 at 11:45 AM revealed: two (2) sit to stand lifts on the 100 hallway both with a transfer sling still attached. The surveyor asked the Registered Nurse (RN) Unit Manager #12 if transfer slings were allowed to be stored on the sit-to-stand lifts in the hallway when not in use, and she stated It shouldn't be on it, I would say. f) On 05/11/26 at 11:50 AM eight (8) dining room chairs were damaged and not easily cleanable. g) On 05/11/26 at 11:55 AM two (2) sit-to-stand lifts on the 400 hallway both had a transfer sling still attached. h) On 05/11/26 at 11:56 AM one (1) sit-to-stand lift on the 300 hallway still had a transfer sling attached. i) One (1) Geri chair on the 300 hallway was soiled and had a tear that would not be easily cleanable. j) On 05/12/26 at 11:15 AM, two (2) Geri chairs on the 100 hallway were soiled with debris. The surveyor asked LPN #59 if one (1) of the Geri chairs looked clean to her, and she stated, I don't think it is, I will take it and clean it now. On 05/12/26 at 12:35 PM the ADON gave the surveyor a policy for laundering the transfer slings, but did not have a policy for storing them. She stated, The transfer slings should be stored in the residents room that the sling is being used on at that time. The ADON also stated, We do not have a policy on cleaning and storing wheel chairs and Geri chairs, but we do clean them every day on night shift. She acknowledged that some were missed and said we will get a better process in place. k) On 05/13/26 at 9:00 AM the six (6) chairs surrounding the table in the internet cafe room were all damaged and not easily cleanable. On 05/13/26 at 10:15 AM the surveyor interviewed the Administrator about the damaged chairs located in the internet cafe and the dining room. After showing her the damaged chairs, she stated, I agree that these chairs are damaged and need to be replaced. I will order new ones soon.

Based on observations and staff interviews, the facility failed to maintain a clean, safe and comfortable homelike environment for the residents. The surveyors observed various maintenance issues and items requiring cleaning. Resident identifiers: #7, #29, #50, and #111. Census: 116. Findings include: a) On May 11, 2026 at approximately 11:45 AM during a routine walkthrough of the 300 hallway, the following was observed: A high-back wheelchair near 301 had brown stains, was visibly soiled, and showed cracks and splitting of the vinyl. Nurse Aide #116 said, Housekeeping cleans them on a schedule usually. when asked who cleans and maintains the wheelchairs. Observation revealed the sit to-stand (STS) lift at the end of the hall (300) near rehab had a sling draped across it. Interview with CNA #116 they are not supposed to be stored on the lifts, there is a space at the end of the hallways. Wall paper is torn and peeling off the wall near rehab at end of 300 hall During an interview with Nurse Aide (NA) #116 the NA said, That's been that way a while. b) Resident #50 Resident #50 has damaged/exposed plaster behind their bed. c) Resident #29 Resident #29 has damaged plaster near and behind their bed. d) Resident #7 Resident #7 had damaged/exposed plaster behind their bed. All these rooms contained visible large areas of damage to the walls and plaster surfaces. These areas were all larger than a dollar bill in size, with some having deep gouges and holes exposing the gypsum underneath. The surveyor conducted a walkthrough with the Administrator and Director of Nursing (DON) to point out these issues and ask for more information after discovering them. The Administrator and DON were asked to provide the following policies regarding the cleaning and maintenance of the facility as well as the residential areas. Wheelchair cleaning and maintenance Wall cleaning and repair policy The Administrator stated she did not have any of the above requested policies 05/11/26 at 1:45 PM On 05/11/26 at 2:44 PM the administrator and director of nursing (DON) stated they are addressing the wallpaper damage, cleaning the wheelchair (w/c), and removing all slings for proper storage. They are also doing education for staff. e) Resident #111 On 05/11/26 at 11:29 AM, the surveyor observed that Resident #111's room contained a recliner with dried white substance smears on the seat. During a walk through with the Assistant Director of Nursing, on 05/12/26 at 1:50 PM, she acknowledged the dried white substance smears on the seat and stated she would make sure it was on the list for to be cleaned.

Based on observation and staff interview. The facility failed to ensure items for resident meal use are air dried prior to use. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census 116.Findings include: a) Policy review for ware washing included the following: Policy statement: All dishware, service ware, and utensils will be cleaned and sanitized after each use.Procedures read in part:4. All dishware will be air dried and properly stored. During the initial walk-through on 05/11/26 at around 11:30 AM with the Food Service Director in the dish tank area: wet nesting was observed with four (4) of four (4) Kennedy cups and eight (8) of twelve (12) cereal bowls. Food Service Manager verified these items remained wet During the follow-up kitchen observation with the Food Service Director on 05/12/2026 at around 10:30 AM, wet nesting was observed again in the dish tank area. Ten (10) of twelve (12) cereal bowls were placed in a bus tub, stacked on each other. The Manager reported, I thought it was ok like this since they were stacked for some space. He then reviewed the warehousing policy and reported, I will try to find something to use.The Director of Operations (DOO) was also in the dish tank area and verified the wet nesting in the cereal bowls placed in the bus tub. The DOO said, We will try to order some extra drying racks.

Based on observation, record review, and staff interview the facility failed to provide dental services for Resident #110. Resident Identifier #110. Facility Census 116.Findings include:a) Resident #110 On 05/11/2026 at 3:08 PM, during initial interview with Resident #110, she had concerns about having a dental appointment for dentures. Review of records and staff interviews showed her last dental appointment was scheduled for 01/23/25. It was documented that Resident #110 was sick and did not attend the appointment. The appointment was never rescheduled. Assistant Director of Nursing verified this appointment was not rescheduled on 05/13/26 at 11:10 AM.

Based on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was within reach. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #117. Facility Census: 116.Findings included:a) Resident #117The facility's policy and procedure for Resident Rights stated, c. To have a method to communicate needs to staff. i. Call light or bell access will be within reach of the resident as one method to communicate needs to staff. On 05/12/26 at 11:20 AM, during an interview with Resident #117, he was reaching around his bed looking for something. I asked him if he was looking for his call light, and he stated, No, but it is hanging up there, I don't know why they put it up there. Resident #117 was referring to his call light hanging on his over-the-bed light, which was located behind and above his bed.Registered Nurse (RN) #96 entered the room with Resident #117's lunch meal tray. I asked her if she thought Resident #117 could reach his call light? She stated, No, he can't. Then she moved it to his bed on his left side. Resident #117 was pleased with the location to which Employee #96 moved it.

Based on observation and staff interviews, the facility failed to store garbage and refuse in a proper manner to prevent rodents, vermin and pests. The dumpsters were in disrepair. This had the potential to affect all residents that reside in the facility. Facility census: 117. Findings included: a) Dumpsters On 10/05/24 at 1:47 PM an observation of the dumpsters found one (1) dumpster with a rusty hole in the bottom front with debris hanging out. Dumpster two (2) was in disrepair as the middle doors were unable to close properly do to damage. On 10/05/24 at 1:50 PM during an Interview the Maintenance Director stated that he was aware of the issues with the dumpsters. He continued to say that he has got quotes for new dumpsters, but the facility has not purchased them at this time.

Based on observation, and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment, with housekeeping, and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was a random opportunity for discovery. Bathroom identifiers: room [ROOM NUMBER], #114, #107, #112. Resident identifier: #94. Facility Census: 117 Findings include: a) room [ROOM NUMBER]: During an inspection of the bathroom in room [ROOM NUMBER] on 11/07/24 at approximately 10:17 AM, a brown substance was observed between the tiles near the commode. room [ROOM NUMBER]: During an inspection of the bathroom in room [ROOM NUMBER] at approximately 10:20 AM on November 7, 2024, a brown substance was observed on the tiles around the toilet. Additionally, sections of the baseboard under the sink were missing, and the drywall in that area needed repair and repainting. During an inspection on 11/07/24 at approximately 9:35 AM the following resident rooms were noted to have the following room [ROOM NUMBER] Gaps were observed in the floor tiles near commode room [ROOM NUMBER] Gaps were observed in floor tiles near commode Corporate Clinical Nurse (CCN) #200 was informed of the issues on 10/07/24 at approximately 10:55 AM and confirmed that the bathrooms were unsanitary. She subsequently notified housekeeping that the bathrooms needed to be cleaned. 50801 b) Resident#94 Observation of Resident # 94's bathroom, on 11/07/2024 at 3:30 pm revealed the facility failed to provide a clean, home like environment. A hole in the drywall was patched but not painted on the bathroom wall, above the sink. On 11/07/2024at approximately 9:00 AM The DON stated she had observed Resident # 94's bathroom wall had a drywall patch that had not been completed or painted. She did not provide any plans to complete the repairs.

Based on record reviw and staff interview, the facility failed to keep a resident's Health Care Surrogate / legal decision-maker informed of her health status and medical condition. The deficient practice prevented the legal decision-maker from being informed, in advance, of the care to be furnished. This was true for one (1) of 24 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #74. Facility census: 117. Findings included: a) Resident #74 An electronic medical record review, conducted on 11/05/24 at 9:10 PM, revealed: -Resident #74 had been admitted to the hospital on 07/15/24. -During Resident #74's stay in the hospital, it was determined that the resident did not have the capacity to make medical decisions, and a Health Care Surrogate (HCS) was appointed to be the legal decision maker on Resident #74's behalf. -The hospital's 07/18/24 After Visit Summary stated that a surrogate decision-maker had been recorded during resident's hospitalization . Details of the After Visit Summary were scanned in Resident #74's electronic medical record. However, the HCS form appointing a legal decision maker on Resident #74's behalf was not part of medical record. -A nurses note, dated 07/24/24 at 9:21 AM, stated that the nurse practitioner had been made aware of lab results with no new orders at this time. It also stated, Resident aware. There was no evidence that resident's HCS had been notified. -An appointment note, dated 08/01/24 at 8:49 AM stated that resident had a follow-up neurology appointment on 08/23/24 at 1:00 PM. It also stated, MD (medical doctor) and resident aware. There was no evidence that resident's HCS had been notified. - An activities progress note, dated 07/31/24 at 10:15 AM, stated that the Activity Director issued resident a care conference letter on 07/31/24. There was no evidence that resident's HCS had been invited to attend the care plan meeting. During an interview on 11/06/24 at 3:10 PM, the Director of Nursing acknowledged the facility was unable to produce evidence that Resident #74's HCS had been properly identified following her 07/15/24 hospitalization . Furthermore, the DON acknowledged the facility could not provide evidence that the HCS had been kept informed of resident's health status.

43340 Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to residents/resident representatives for four (4) of five (5) residents reviewed for hospitalization s during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: #167, #74, and #28. Facility census: 117. Findings included: a) Resident #167 A medical record review was completed on 11/05/24 at 8:42 PM. The record review revealed Resident #167 was transferred to the hospital on 10/28/24. The record did not reflect the resident/resident's representative was provided with a written Notice of Transfer/Discharge indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights. During an interview on 11/07/24 at 9:05 AM, the Director of Nursing (DON) reported the facility could produce no evidence that resident/resident's representative was provided a Notice of Transfer/Discharge. b) Resident #74 A medical record review was completed on 11/05/24 at 7:02 PM. The record review revealed Resident #74 was transferred to the hospital on 07/15/24. The record did not reflect the resident/resident's representative was provided with a written Notice of Transfer/Discharge indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights. During an interview on 11/07/24 at 9:06 AM, the Director of Nursing (DON) reported the facility could produce no evidence that resident/resident's representative was provided a Notice of Transfer/Discharge. c) Resident #28 Review of Resident #28's medical records revealed the resident was transferred to the hospital due to decreased levels of consciousness on 07/06/24, returning to the facility on [DATE], and on 07/21/24, returning to the facility on [DATE]. For these dates, the resident's electronic health record did not contain notices of transfer or discharge giving the reason for the transfer and information regarding appeal rights. On 11/07/24 at 11:30 AM, the Director of Nursing confirmed notices of transfer or discharge were not given for Resident #28's hospital transfers on 07/06/24 and 07/21/24. No further information was provided through the completion of the survey process. 50801

Based on record review, and staff interview, the facility failed to follow physician orders related to insulin. This was true for one (1) of five (5) residents reviewed for the unnecessary medication review during the annual long-term care survey process. Resident identifier: #56. Facility census: 117. Findings included: a) Resident #56 A record review was completed on 11/05/24 at 6:15 PM. The record review demonstrated that Resident #56 had a diagnosis of diabetes mellitus and had a sliding scale order for insulin. The term sliding scale refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges. Sliding scale insulin regimens approximate daily insulin requirements. The order stated to call the physician if the resident's blood glucose level went above 400. There was no evidence in the electronic medical record that the physician had been notified of a blood glucose level above 400 on the following dates: -05/07/24 at 8:00 PM, Blood Sugar (BS) of 449 -05/08/24 at 8:00 PM, BS of 402 -05/13/24 at 8:00 PM, BS of 404 -06/02/24 at 8:00 PM, BS of 415 -06/06/24 at 8:00 PM, BS of 435 -06/14/24 at 4:30 PM, BS of 417 -06/15/24 at 4:30 PM, BS 0f 402 -06/16/24 at 4:30 PM, BS of 445 -07/06/24 at 8:00 PM, BS 0f 403 -07/08/24 at 4:30 PM, BS of 440 -07/11/24 at 4:30 PM, BS of 417 -07/12/24 at 8:00 PM, BS of 450 -07/13/24 at 8:00 PM, BS of 445 -07/14/24 at 8:00 PM, BS of 430 -07/16/24 at 8:00 PM, BS of 426 -07/17/24 at 8:00 PM, BS of 439 -07/22/24 at 8:00 PM, BS of 414 -07/26/24 at 8:00 PM, BS of 421 -07/27/24 at 8:00 PM, BS of 449 -08/11/24 at 8:00 PM, BS of 481 -08/26/24 at 7:30 AM, BS of 440 -09/14/24 at 4:30 PM, BS of 416 -09/23/24 at 7:30 AM, BS of 426 -09/31/24 at 8:00 PM, BS of 428 During an interview on 11/06/24 at 3:40 PM, the Assistant Director of Nursing reported the facility could produce no evidence the physician had been contacted on the above-mentioned dates.

Following record review and interviews, the facility failed to obtain an order to utilize a pain scale for the administration of pain medication. Additionally, facility staff did not assess residents after administering pain medication, to ensure effective pain management, as per professional standards of practice. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #103 and #319. Facility census: 117. Findings included: a) Resident #103: Record review, and interview, revealed that Resident #103 had been prescribed the following medication: Tylenol Oral Tablet 325 MG X2 every 6 hours as needed for pain. Order date 08/11/24 at 11:13 AM. Record review conducted on 11/05/24, at approximately 10:00 AM revealed that a pain scale had not been prescribed for the administration of medication. Staff administered medication even when the resident's pain level was recorded as zero (0). Additionally, there were no documented assessments of post-administration pain levels available for review, to evaluate the effectiveness of pain management. The following random sampling revealed dates, administered medication, and resident's stated pre-medication pain levels: 08/11/24 11:25 AM Pain Level: 5 Medication Administered: Tylenol Oral Tablet 325 MG X2 08/11/24 9:21 PM Pain Level: 5 Medication Administered: Tylenol Oral Tablet 325 MG X2 08/13/24 9:00 PM Pain Level: 10 Medication Administered: Tylenol Oral Tablet 325 MG X2 08/16/24 10:06 AM Pain Level: 5 Medication Administered: Tylenol Oral Tablet 325 MG X2 08/16/24 9:20 PM Pain Level: 10 Medication Administered: Tylenol Oral Tablet 325 MG X2 08/26/24 11:01 AM Pain Level: 0 Medication Administered: Tylenol Oral Tablet 325 MG X2 08/26/24 8:57 PM Pain Level: 4 Medication Administered: Tylenol Oral Tablet 325 MG X2 09/10/24 11:51 AM Pain Level: 0 Medication Administered: Tylenol Oral Tablet 325 MG X2 09/11/24 7:28 AM Pain Level: 4 Medication Administered: Tylenol Oral Tablet 325 MG X2 09/14/24 8:14 PM Pain Level: 3 Medication Administered: Tylenol Oral Tablet 325 MG X2 09/18/24 8:00 PM Pain Level: 10 Medication Administered: Tylenol Oral Tablet 325 MG X2 09/26/24 9:19 AM Pain Level: 1 Medication Administered: Tylenol Oral Tablet 325 MG X2 10/04/24 9:10 AM Pain Level: 2 Medication Administered: Tylenol Oral Tablet 325 MG X2 10/06/24 8:36 PM Pain Level: 9 Medication Administered: Tylenol Oral Tablet 325 MG X2 10/07/24 7:52 AM Pain Level: 0 Medication Administered: Tylenol Oral Tablet 325 MG X2 10/15/24 7:25 AM Pain Level: 2 Medication Administered: Tylenol Oral Tablet 325 MG X2 10/16/24 8:35 AM Pain Level: 1 Medication Administered: Tylenol Oral Tablet 325 MG X2 10/29/24 12:15 AM Pain Level: 3 Medication Administered: Tylenol Oral Tablet 325 MG X2 10/30/24 9:00 PM Pain Level: 10 Medication Administered: Tylenol Oral Tablet 325 MG X2 11/04/24 8:12 AM Pain Level: 5 Medication Administered: Tylenol Oral Tablet 325 MG X2 b) Resident #319: Record review, and interview on 11/05/24 at 9:09 AM, revealed that Resident #319 had been prescribed the following medication: Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) 1 tablet by mouth every 8 hours as needed for pain. PRN pain medication. Order date 10/29/2024 at 4:45 PM. Further review indicated that no pain assessment scale was specified for the administration of the medication. During an interview with Licensed Practical Nurse (LPN) #133 on 11/06/24 at approximately 9:05 AM, she stated that there was no pain scale for the administration of pain medication, and no assessments were conducted after administration. At approximately 9:08 AM on 11/06/24, during an interview with LPN #15, she stated that pain levels were not assessed or documented after medication administration. On 11/06/24, at approximately 10:00 AM, during an interview with the Director of Nursing (DON), this surveyor requested documentation on pain scales used for administering the medications, Acetaminophen or Oxycodone, for Residents # 117 and #319. The DON confirmed that no pain scales had been prescribed. Additionally, the DON acknowledged that there were no documented post-medication pain levels to ensure that the residents were receiving adequate pain management. At approximately 2:51 PM on 11/06/24, the Corporate Clinical Nurse (CCN) #200 reported that she had requested pain scales for the administration of pain medication. She also mentioned that she implemented teaching sessions, and in-services for the nursing staff, to ensure that residents were properly assessed and adequately medicated for pain.

Based on record review and staff interview, the facility failed to complete annual performance reviews for Nurse Aides (NA). This was true for five (5) of five (5) reviewed for staffing during the Long-Term Survey Process (LTCSP). Facility census: 117. Findings included: a) Facility NA's Annual Evaluations A facility record review revealed NA #29, NA #34, NA #60, NA #14, and NA #18 did not receive their 12-month evaluation. During an interview, on 11/06/24 at 4:04 PM, the Human Resource Manager confirmed there were no annual evaluations completed for NA #29, NA #34, NA #60, NA #14, and NA #18. She stated that NA evaluations were something the facility was working on getting completed.

Based on record review, and staff interview, the facility failed to ensure the physician documented the actions or rational if no action taken to monthly drug regimen reviews. This was true for four (4) of five (5) reviewed for unnecessary medications and the pharmacist failed to identify clinically significant risks associated with concurrent use of a Benzodiazepines and opioids. Resident identifiers: #22, #77, #101 and #17. Facility census: 117. Findings included: a) Resident #22 Record review of the facility's policy titled, Medication Regimen Review, showed: -Attending Physician Responsibilities: 1. The resident's attending physician must document in the medical record that the identified irregularity has been reviewed, and what if any action has been taken to address it. 2. If there is to be no change in the medications, the attending physician must document his/her rationale in the resident's medical record. A medical record review for Resident #22 revealed monthly drug regimen reviews response without actions or rational if no action taken by the physician. --06/27/24 Recommendation -Psychotropic (Non-Antipsychotic) on as needed (PRN) basis Hydroxyzine Pamoate 25 mg. Per regulatory guidelines, the duration of treatment with such medications on PRN basis should be limited to 14 days. --07/23/24 Recommendation Resident currently has order to obtain Vitamin D, TSH and FLP every 6 months. The last results are 11/14/23. During an interview on 11/06/24 at 11:02 AM the Director of Nursing verified that the physician did not document the action or rational. b) Resident #77 A medical record review for Resident #77 revealed monthly drug regimen reviews response without actions or rational if no action taken by the physician. --05/28/24 Recommendation - Resident is currently taking Divalproex 500 MG BID. There is no standing order to have a divalproex level checked routinely. Please consider adding an order to monitor Divalproex level every 6 months. --08/27/24 Recommendation this resident receives Vitamin D 50,000 units once weekly. No vitamin D level in resident chart. Please consider monitoring a Vitamin D level every 3 months. During an interview on 11/06/24 at 11:02 AM the Director of Nursing verified that the physician did not document the action or rational. c) Resident #17 A review of Resident #17's records on 11/06/24, at approximately 12:45 PM, revealed that the resident was currently prescribed the following medications: 1. Ativan Oral Tablet 0.5 MG (Lorazepam) - Controlled Drug Administer 1 tablet by mouth three times a day for generalized anxiety due to yelling, cursing, and combativeness. Order date: August 23, 2023, at 10:30 AM. 2. Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Administer 1 tablet by mouth three times a day for moderate to severe chronic pain, not to exceed 3 g of acetaminophen in 24 hours. Order date: July 18, 2023, at 9:00 PM. 3. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) - *Controlled Drug Administer 0.25 ml by mouth every 2 hours as needed for severe pain. Order date: January 17, 2023, at 2:49 PM. A review of the guidance by the Centers for Disease Control, dated November 4, 2022, titled: CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022 showed the following under Recommendation 11. Clinicians should check the Prescription Drug Monitoring Program (PDMP) for concurrent controlled medications prescribed by other clinicians .and should consider involving pharmacists as part of the management team when opioids are co-prescribed with other central nervous system depressants. In patients receiving opioids and Benzodiazepines long term, clinicians should carefully weigh the benefits and risks of continuing therapy with opioids and Benzodiazepines and discuss with patients and other members of the patient's care team. Clinicians should communicate with other clinicians managing the patient to discuss the patient's needs, prioritize patient goals, weigh risks of concurrent Benzodiazepines and opioid exposure, and coordinate care. Benzodiazepines and opioids both cause central nervous system depression, and Benzodiazepines can potentiate opioid-induced decreases in respiratory drive. Epidemiologic studies find concurrent Benzodiazepines use in large proportions of opioid-related overdose deaths. Record review and staff interview conducted on October 7, 2024, at approximately 8:30 AM revealed that the consulting pharmacist did not identify, or notify the physician about clinically significant risks and potential adverse consequences associated with the concurrent use of Benzodiazepines and opioids. Furthermore, the attending physician failed to provide the nursing staff with instructions for properly assessing and monitoring the effectiveness of the medications, as well as for detecting adverse consequences such as depressed respiration or sedation. This includes a lack of guidance on how, and when, to monitor the resident's symptoms to ensure their safety while on this medication regimen. During an interview with Licensed Practical Nurse (LPN) #133 on 11/06/24 at approximately 9:05 AM, she stated that there was no pain scale for the administration of pain medication, and no assessments were conducted after administration. At approximately 9:08 AM on 11/06/24, during an interview with LPN #15, she stated that pain levels were not assessed or documented after medication administration. During an interview with the Director of Nursing (DON) on 11/07/24 at approximately 9:18 AM, she confirmed that the physician prescribed no assessment guidelines and that the nurses do not monitor residents' respirations. d) Resident #101 The facility failed to provide signed and written documentation in the medical record that the identified irregularity has been reviewed and what, if any, action had been taken to address it. Pharmacists consults dated 02/26/24, and 6/25/24, 06/29/24 revealed the pharmacist found Irregularities noted and/or recommendation(s) made. 02/26/24 Resident's current order of Lorazepam PRN. There are no instruction on frequency of administration on the order. The discharge medication list has TID (three times a day) PRN (as needed). Please confirm and update the order for patient safety and concern. Nicotine and Melotonin were not entered. Anxiolytic behavior monitoring are not complete. On 06/20/24 the Resident admission medication regimen was assessed issues and concerns: This resident is currently receiving Heparin TID after a recent hospital visit. Recommendation for stop date for Heparin. There was no signed and written documentation in the medical record that the identified irregularity has been reviewed and what, if any, action had been taken to address it. 50795 50801

Based on observation and staff interviews, the facility failed to keep unit refrigerators free from medical supplies that could contaminate food and store food and supplies in accordance with professional standards for food service safety. This has the ability to affect more than a limited number of Residents. Facility census: 117. Findings included: a) Unit Pantry's During the initial tour of pantries with the Dietary Manager on 11/04/24 at 11:30 AM an observation of the south pantry found five (5) used resident cold gel Icepacks for injury or surgical procedures stored in the Resident freezer. The continued tour of the north pantry on 11/04/24 at 11:44 AM found five (5) used resident cold gel Icepacks for injury or surgical procedures stored in the Resident freezer and the ice scoop stored in the ice cooler. On 11/04/24 at 12:00 PM during an interview with the Dietary Manager (DM) verified that medical supplies should not be stored in Resident refrigerators or freezers and the ice scoop should be placed in the scoop holder, not in the ice chest.

Based on record review and staff interview, the facility failed to maintain accurate records on four (4) out of 24 sampled residents in the Long-Term Care Survey Process. Resident identifiers: #71, #68, #110, and #93. Facility census: 117. Findings included: a) Resident #71 A record review, on 11/04/24 at 12:44 PM, revealed a Physician Orders for Scope of Treatment (POST) form in Resident #71's electronic medical record. The POST form was dated 07/30/22. Section E of the POST form, entitled Signature: Patient or Patient Representative/Surrogate/Guardian was unsigned and undated. On 11/05/24 at 2:45 PM, a review of resident's paper chart at nurses' station revealed the original POST was also not signed by resident/resident representative. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, state, The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. During an interview, on 11/05/24 at 3:15 PM, the Director of Social Services acknowledged the POST form was not completed according to guidance and could not be considered legally valid. b) Resident #68 A record review, on 11/04/24 at 1:38 PM, revealed a POST form in Resident #68's electronic medical record. The POST form was dated 10/17/23. Section F of the POST form, entitled Signature: Health Care Provider was undated. On 11/05/24 at 2:47 PM, a review of resident's paper chart at nurses' station revealed the original POST also had no date with the physician's signature under Section F. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, state, The health care provider completing this form must print their name, sign, and date this section for the form to be legally valid. During an interview, on 11/05/24 at 3:17 PM, the Director of Social Services acknowledged the POST form was not completed according to guidance and could not be considered legally valid. c) Resident #110 Review of Resident #110's medical records showed a POST form. A POST form is completed by the resident or resident's representative to indicate end-of-life wishes. Resident #110 did not have capacity to make medical decisions. A POST form had been completed and signed by the resident's representative. However, the resident's representative's signature had been dated. The physician had signed the POST form and dated the form on 08/09/24. However, the physician did not print his or her full name on the form. The signature was illegible. The POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, available on-line, stated as follows: - The patient (or incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate) must sign and date this section for the form to be legally valid. - The health care provider completing this form . must print their name, sign, and date this section for the form to be legally valid. On 11/06/24 at 10:40 AM, the Assistant Director of Nursing (ADON) confirmed Resident #110's POST form had not been fully completed. d) Resident #93 Record review on 11/05/24 at 9:25 AM revealed a physician determination of capacity form dated 08/23/24, that stated that the resident suffered from: Disorientation Inability to Process Information Delirium Encephalopathy However, the physician inaccurately documented that Resident #93 had capacity by checking off the box that stated: Demonstrates CAPACITY to make decisions. Record review revealed a Brief Interview for Mental Status (BIMS) for Resident #93, dated 08/29/24 that showed a BIMS score of 15. Further investigation and record review revealed a State Of [NAME] Virginia Checklist for Surrogate Selection dated 08/23/24 that had designated the resident's daughter-in-law as the surrogate. During an interview with the Director of Social Services (DSS) on 11/05/24 at approximately 2:30 PM to discuss the discrepancies, the DSS stated that the resident responded appropriately to the questions and was having a good day when the BIMS assessment was done. On 08/29/24. DSS further stated that Resident #93 has good days and bad days. An interview was conducted with the Director of Nursing (DON) on 11/05/24 at approximately 2:45 PM, and the DON confirmed that the physicians' determination of the resident's capacity was inaccurate. The DON returned at approximately 3:45 PM with an updated form dated 11/05/24, signed by the physician's designee, which stated that Resident #93 did not have capacity. 39043 50795

Based on record review and interview, the facility failed to notify the resident's legal representative of a change in health status and transfer to the hospital. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #74. Facility census: 117. Findings included: a) Resident #74 An electronic medical record review, conducted on 11/05/24 at 9:10 PM, revealed: -A nurses note, dated 07/15/24 at 6:00 PM, stated, Resident transferred to [Name of a local hospital] as direct admit. Transported via facility staff and van. Left facility in stable condition. Resident with capacity. MD (medical doctor) aware. There was no evidence that resident's emergency contact/family member had been notified of the need for acute care or transfer to the hospital. -An eInteract Transfer form, dated 07/15/25 at 8:00 PM, indicated that Resident #74 was her own resident representative and that she was aware of the acute transfer and her clinical situation. During an interview on 11/06/24 at 3:10 PM, the Director of Nursing (DON) acknowledged the facility was unable to produce evidence that Resident #74's emergency contact/family member had been notified of the need for an acute care transfer to the hospital. The DON stated resident had capacity and was aware of the need to be sent to the hospital. Surveyor reviewed CMS [Centers for Medicare and Medicaid Services] guidance with the DON which indicated, even if a resident is competent, the resident representative should be notified of significant changes in health status because the resident may not be able to notify them themselves. The DON acknowledged the facility had failed to communicate with resident's emergency contact/family member.

Based on record review and staff interview, the facility failed to facilitate the inclusion of the resident representative in person-centered care planning. This was true for one (1) of 24 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #74. Facility census: 117. Findings included: a) Resident #74 An electronic medical record review, conducted on 11/05/24 at 9:10 PM, revealed: -Resident #74 had been admitted to the hospital on 07/15/24 -During Resident #74's stay in the hospital, it was determined that the resident did not have the capacity to make medical decisions, and a Health Care Surrogate (HCS) was appointed to be the legal decision maker on Resident #74's behalf. -The hospital's 07/18/24 After Visit Summary clearly stated that a surrogate decision-maker had been recorded during resident's hospitalization . Details of the After Visit Summary were scanned in Resident #74's electronic medical record. However, the HCS form appointing a legal decision maker on Resident #74's behalf was not part of medical record. - An activities progress note, dated 07/31/24 at 10:15 AM, stated that the Activity Director issued resident a care conference letter on 07/31/24. There was no evidence that resident's HCS had been invited to attend the care plan meeting. During an interview, on 11/06/24 at 3:10 PM, the Director of Nursing acknowledged the facility was unable to produce evidence that Resident #74's HCS had been properly identified following her 07/15/24 hospitalization . Furthermore, the DON acknowledged that the facility could not provide evidence that the HCS had been invited to the above-mentioned care plan meeting.

Based on record review and staff interview, the facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #269. Facility census: 117. Findings included: a) Beneficiary Notice Review On 11/05/24 at 7:25 PM, a review was completed regarding the beneficiary protection notification liability notice(s) given for Resident #269 who was discharged to home with a family member following his last covered day of Medicare Part A services. Resident #269's last covered day of Part A Services was on 09/05/24. There was no evidence in the electronic medical record that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Further review of the electronic medical record revealed the following details: -An 08/22/24 summary of resident's discharge plans reflected that resident had capacity and that he desired to be discharged back to the community (to home with a family member) and with home health services. -An 08/23/24 Social Services note stated, Resident will be returning to the community. and He will be going back to live with his [family member] when he discharges. -An 08/26/24 Social Services note stated, Resident's plans to discharge back to the community and will be living with his [family member] when his inpatient treatment is complete. -An 08/29/24 MDS note stated, Plans to d/c (discharge) home with [family member] when able. -A 09/04/24 Clinical Meeting note stated, Resident plans to d/c home after therapy services completed. Review of therapy discharge summaries (physical therapy, speech therapy, and occupational therapy), completed on 11/06/24 at 9:40 revealed the following details: -The Physical Therapy Discharge Summary stated the discharge reason was Highest Practical Level Achieved. -The Speech Therapy Discharge Summary stated the discharge reason was Highest Practical Level Achieved. -The Occupational Therapy Discharge Summary stated the discharge reason was All Goals Met. During an interview on 11/06/24 at 10:10 AM, the Business Office Manager confirmed a NOMNC was not issued prior to Resident #269's last covered day of Medicare Part A skilled services and subsequent discharge to home.

Based on random observations and interviews, the facility failed to ensure a Resident's medical and health information was protected during MDS Interviews. Resident identifiers: #18 and #77. Facility census: 117. Findings included: a) Resident #18 A random observation on 11/04/24 at 1:33 PM, overheard the MDS Licensed Practical Nurse #16 Interviewing Resident #18 from the hallway. The Brief Interview for Mental Status was being assessed. Resident #18's door was open and MDS LPN was speaking loudly. This practice found resident's answers could be overheard by other residents, staff and visitors. b) Resident #77 A random observation on 11/05/24 at 2:38 PM, overheard MDS Licensed Practical Nurse #16 interviewing Resident #77 from the hallway. The Brief Interview for Mental Status was being assessed. Resident #77 was sitting in the MDS open doorway and MDS LPN was speaking loudly. This practice found resident's answers could be overheard by other residents, staff and visitors. On 11/05/24 at 2:40 PM, an interview with the Social Service Director confirmed the information could be overheard. The Social Service Director went at this time to close the MDS door.

Based on record review and staff interview, the facility failed to ensure the appropriate information was communicated to the receiving health care institution when the facility transferred Resident #167 to the hospital. This deficient practice was true for one (1) of five (5) residents reviewed under the hospitalization pathway. Resident identifier: #167. Facility census: 117. Findings included: a) Resident #167 An electronic medical record review, completed on 11/05/24 at 8:42 PM, reflected that resident was transferred to the hospital on 10/28/24. There was no evidence that an eInteract Transfer form had been completed or that the following items had been sent with the resident upon his transfer to the hospital: -Contact information of the practitioner responsible for the care of the resident -Resident representative information including contact information -Advance Directive information -All special instructions or precautions for ongoing care, as appropriate -Comprehensive care plan goals -All other necessary information and any other documentation, as applicable, to ensure a safe and effective transition of care During an interview on 11/07/24 at approximately 9:40 AM, the Director of Nursing reported the facility could not produce evidence the appropriate discharge paperwork had been sent with Resident #167 when he was transferred to the hospital.

Based on record review, resident interview, and staff interview, the facility neglected to ensure a process was in place for a safe discharge for Resident #12. The Resident was discharged to a homeless shelter. The Resident had no prior knowledge he would be discharged to the shelter until the day of discharge. Medications were sent with the resident; however, the Resident had no knowledge of how to take the medications. The Resident had no follow up appointments with any physician for further care and no services arranged for outside the facility. The Resident was not provided with a 30 day notice of discharge. Harm occurred when an interview with the Resident confirmed he was unable to administer his medications and care for himself after he arrived at the shelter. The Resident said he felt uneasy and his nerves were shot when he was discharged to the shelter. He said he was unable to make it from the building he slept in to a separate building containing the dining area for meals because of his nerves. The Resident was sent to a local hospital by the shelter when he began vomiting blood. The Resident was admitted to the hospital for a bleeding ulcer and remains at the hospital until he can find a nursing home or a facility to assist with his care. The Resident had no issues with the nursing home and did not express a desire to leave the facility. This was found for one (1) of four (4) residents reviewed for discharge during a complaint survey. Resident identifier: #12. Facility census: 109. Findings included: a) Resident #12 Record review found Resident #12 was admitted to the facility on [DATE] from a rehabilitation facility. When admitted to the facility, the resident had a health care surrogate and was deemed to lack capacity to make medical decisions. On 12/07/21, the facility physician determined the resident has capacity to make medical decisions. Record review found the resident was discharged to a homeless shelter from the facility on 04/17/23. The admission history and physical on 12/06/21: SUBJECTIVE: (name of resident and age) male with history of ETOH (alcohol) abuse, HTN (hypertension), bipolar disorder,psoriasis, ad chronic pain who was seen today for admission H/p following a long course involving (Name of Hospital and Name of acute rehabilitation center) He originally presented to (Name of hospital) on 11/4 with RLE (right lower extremities) cellulitis and necrotizing fascitis. His hospital course was complicated by acute anemia and GI bleeding, leading to vascular issues and inability to heal is lower extremity wounds. He eventually underwent an AKA (above the knee amputation) of the right leg. He slowly recovered and was then transferred to (Name of rehabilitation center) He did well with PT (physical therapy) and has been transferred here to (Name of nursing home ) for further rehab/skilled care . The following notes were found in the medical record for 04/17/23: 2 04/17/23 at 12:45 PM-Nurses Note Note Text: Resident discharged to (Name of a homeless shelter.) Resident in stable condition at time of discharge. This nurse attempted to review discharge orders with resident, but resident refused. Copy of discharge orders sent with resident. This nurse reviewed discharge summary with the resident with no questions asked. Resident discharged with all belongings. Medications sent with resident. Resident is alert and oriented x 4. Skin is warm and dry. Respirations even and unlabored. Takes medications whole without difficulty. Feeds self all meals. NP (Nurse Practioner) aware of discharge. A second entry on 04/17/23 at 12:30 PM Nurses Note Late Entry: Note Text: This nurse spoke with (Name of a female) at the (Name of homeless shelter.) She said that staff there will assist resident with obtaining meds and will assist him with finding a house once he is there, but they can not provide services if he is not a client there. Res. was very happy to be able to go and stated, they will help me, they have before. MD (medical director) aware. At the time of discharge the Resident was receiving the following medications for the following diagnoses: Vistaril Capsule 25 milligrams (MG) 1 capsule, 2 times a day for generalized anxiety as evidenced by agitation, yelling, anxiousness. Depakote 250 mg 2 times a day for yelling, cursing, and anxiety related to Bipolar Disorder. Magnesium supplement, 400 mg daily. Omeprazole 20 mg 2 times a day for Gastroesophagal reflux disease (GERD.) Risperdal tablet 0.5 mg, give 1 tablet in the evening for hallucinations and delusions related to Schizophrenia. Senna Tablet 8.6 mg daily for constipation. Zyprexia 10 mg, give 1.5 tablets by mouth in the evening for Schizophrenia. Flomax Capsule 0.4 mg. give in the evening for Benign Prostatic Hyperplasis (BPH.) Gabapentin 100 mg, give 1 capsule by mouth daily for phantom pain. In addition, the Resident has a right above knee amputation prior to coming to the facility. On 05/19/22, the Resident's physician completed a new pre admission screen (PAS) noting the resident progress was stable and rehabilitation was good. The physician checked the box indicating the resident would only need a 3 to 6 months stay at the facility. A second PAS was completed on 12/01/21 by the facility. An interview with the social worker supervisor at 1:07 PM on 05/09/23 found the following reason given for discharging the resident: I came to work here February 2023. He had a PAS completed by the former SW on 12/01/21, he was not approved for nursing home care. Medicaid was not going to pay for his stay. We were talking with him about a place to live. He told me he needed a payee for his check so I contacted an agency that will be representative payee. I sent them the information but haven't heard back on the status. I called some places looking for an apartment for him but they were all full with long waiting lists. The SW provided notes of the above. She stated the homeless shelter was called on the day he left. I was told they had 1 bed but they don't put people on the waiting list. It's a first come first serve basis so we transported him to the shelter before the bed was no longer available. The SW denied notification of the ombudsman regarding the discharge. She said the resident was aware he was leaving on 04/17/23. She was unable to provide any formal notification the resident was told and provided a written discharge notice which included the reason for the discharge, where he would be discharged to, and when the discharge would occur. She said she told him medicaid would no longer pay for his stay and he didn't want to appeal this decision. In addition, the SW was unable to provide a written copy of a 30 day notice of discharge which is required to be provided to the Resident for a facility initiated discharge. The SW provided a Adult Protective Services Mandatory Reporting Form, dated 03/07/23 that included the resident's name birth date , address with the following: Describe physical/cognitive/emotional functioning of the alleged victim: Typed in was the notation: One prosthetic leg needs help with some ADL's (activities of daily living). Has Bipolar disorder and schizophrenia. No other information was on the form to indicate the Resident would be discharged and needed placement. An email was sent to the local Department of Health and Human Services, case worker on 05/08/23. The following was received from the case worker: I know that I had a homeless case open for him (referring to the Resident) and we were looking at placement in an apartment in (Name of a town) I was working on finding clothes and items needed for the apartment since he had nothing. I met with him one time and had contact with Social Worker at the facility about his needs or progress on the apartment matter. I was not informed he was dc (discharged ) until after it happened. They told me that (Name of Homeless Shelter) would be assisting him in locating an apartment and (Name of Nursing Home) would hold his items that we had gathered for him until he needs them. A telephone call to the homeless shelter supervisor revealed the following information on 05/09/23: We are a homeless shelter. People who come here have to take care of themselves. I can assure you no one told the nursing home we give medications or take care of residents. Residents can sleep here and go to a separate house for dining. We noticed the Resident was not eating. I ask him why and he said he could get from the sleeping area to another building for meals, he said it was just too far. I felt bad so we took him food on occasions. A few weeks after he was here, the Resident came to me with some pills in a baggy. He said he didn't know what he was supposed to take. Even if I could help him I had no information on how he should take the medication. We do not dispense medications or help in any way with ADL's. The Resident is currently at the hospital. On 05/06/23 at about 3:14 AM we called an ambulance for him because he was vomiting blood. We do help residents find housing but he didn't know how much money he receives or where his check was even going. He told me, If I need money, I go to the bank, I guess he was referring to the facility bank. When asked if an employee at the Homeless Shelter quoted in the 4/17/23 facility nurses note was available, the reply was, We have no one by that name that works here and no one here that has a name that sounds like like that name. Also the worker confirmed this resident has never been to this shelter before. The Director of Nursing (DON) was interviewed at 3:49 PM on 05/09/23. The DON confirmed the resident was transported to the shelter with the facility van and a driver. As the DON had made the late entry in the medical record, dated 04/17/23 at 12:30 PM she was asked who she spoke with at the shelter. She recited the name quoted in the note. The DON was advised no employee by that name works at the shelter and how could the resident say they had helped him before when he has never been to this homeless shelter. She stated maybe she misunderstood. The DON was asked to provide a care plan which entailed the Resident's discharge plans. She reviewed the care plan at the time of discharge and said it really doesn't have a whole lot of information about his discharge plans. The DON was asked why discharge planning was not started after the 5/19/22 PAS was completed because the facility would have know the Resident could only stay at the facility for up to 6 months. The DON said she really doesn't know because the Social Worker would have been working on that. At 5:30 PM on 05/09/23, the facility minimum data set coordinator Licensed Practical Nurse #103 reviewed the care plan and said there really isn't anything specific about him being discharged immediately. She stated she really wasn't aware the Resident was being discharged . The resident was reached by telephone with the assistance of a case manager at the current hospital on 05/10/23 at 2:24 PM. The Resident said, It made me uneasy when I got to the homeless shelter. I couldn't eat because my nerves were shot. My nerves were shot for going there. The Resident confirmed he did not know what medications he takes and he didn't know what to do with them when he got to the homeless shelter. The Resident said he would like to go to another nursing home when he leaves the hospital. The case manager and the Resident confirmed he was admitted to the hospital for an upper GI bleed. The case worker said she was in the process of completing a new PAS to see if he would qualify for a nursing home. She felt the Resident would not be able to live alone as confirmed by the Resident who doesn't think he can manage a home on his own. The case manager said the Resident was pleasant and cooperative and has not displayed any behaviors while at the hospital.

Based on record review, staff interview and resident interview, the facility failed to provide sufficient preparation and orientation to one (1) of four (4) residents discharged from the facility to ensure a safe and orderly discharge from the facility. The Resident was discharged to a homeless shelter. The Resident had no prior knowledge he would be discharged to the shelter until the day of discharge. Medications were sent with the resident; however, the Resident had no knowledge of how to take the medications. The Resident had no follow up appointments with any physician for further care and no services arranged for outside the facility. Harm occurred when an interview with the Resident confirmed he was unable to administer his medications and care for himself after he arrived at the shelter. The Resident said he felt uneasy and his nerves were shot when he was discharged to the shelter. He said he was unable to make it from the building he slept in to a separate building containing the dining area for meals because of his nerves. The Resident was sent to a local hospital by the shelter when he began vomiting blood. The Resident was admitted to the hospital for a bleeding ulcer and remains at the hospital until he can find a nursing home or a facility to assist with his care. The Resident had no issues with the nursing home and did not express a desire to leave the facility. Resident identifier: #12. Facility census: 109. Findings included: a) Resident #12 Record review found Resident #12 was admitted to the facility on [DATE] from a rehabilitation facility. When admitted to the facility, the resident had a health care surrogate and was deemed to lack capacity to make medical decisions. On 12/07/21, the facility physician determined the resident has capacity to make medical decisions. Record review found the resident was discharged to a homeless shelter from the facility on 04/17/23. The admission history and physical on 12/06/21: SUBJECTIVE: (name of resident and age) male with history of ETOH (alcohol) abuse, HTN (hypertension), bipolar disorder,psoriasis, ad chronic pain who was seen today for admission H/p following a long course involving (Name of Hospital and Name of acute rehabilitation center) He originally presented to (Name of hospital) on 11/4 with RLE (right lower extremities) cellulitis and necrotizing fascitis. His hospital course was complicated by acute anemia and GI bleeding, leading to vascular issues and inability to heal is lower extremity wounds. He eventually underwent an AKA (above the knee amputation) of the right leg. He slowly recovered and was then transferred to (Name of rehabilitation center) He did well with PT (physical therapy) and has been transferred here to (Name of nursing home ) for further rehab/skilled care . The following notes were found in the medical record for 04/17/23: 04/17/23 at 12:45 PM-Nurses Note Note Text: Resident discharged to (Name of a homeless shelter.) Resident in stable condition at time of discharge. This nurse attempted to review discharge orders with resident, but resident refused. Copy of discharge orders sent with resident. This nurse reviewed discharge summary with the resident with no questions asked. Resident discharged with all belongings. Medications sent with resident. Resident is alert and oriented x 4. Skin is warm and dry. Respirations even and unlabored. Takes medications whole without difficulty. Feeds self all meals. NP (Nurse Practioner) aware of discharge. A second entry on 04/17/23 at 12:30 PM Nurses Note Late Entry: Note Text: This nurse spoke with (Name of a female) at the (Name of homeless shelter.) She said that staff there will assist resident with obtaining meds and will assist him with finding a house once he is there, but they can not provide services if he is not a client there. Res. was very happy to be able to go and stated, they will help me, they have before. MD (medical director) aware. At the time of discharge the Resident was receiving the following medications for the following diagnoses: Vistaril Capsule 25 milligrams (MG) 1 capsule, 2 times a day for generalized anxiety as evidenced by agitation, yelling, anxiousness. Depakote 250 mg 2 times a day for yelling, cursing, and anxiety related to Bipolar Disorder. Magnesium supplement, 400 mg daily. Omeprazole 20 mg 2 times a day for Gastroesophagal reflux disease (GERD.) Risperdal tablet 0.5 mg, give 1 tablet in the evening for hallucinations and delusions related to Schizophrenia. Senna Tablet 8.6 mg daily for constipation. Zyprexia 10 mg, give 1.5 tablets by mouth in the evening for Schizophrenia. Flomax Capsule 0.4 mg. give in the evening for Benign Prostatic Hyperplasis (BPH.) Gabapentin 100 mg, give 1 capsule by mouth daily for phantom pain. In addition, the Resident has a right above knee amputation prior to coming to the facility. On 05/19/22, the Resident's physician completed a new pre admission screen (PAS) noting the resident progress was stable and rehabilitation was good. The physician checked the box indicating the resident would only need a 3 to 6 months stay at the facility. A second PAS was completed on 12/01/21 by the facility. An interview with the social worker supervisor at 1:07 PM on 05/09/23 found the following reason given for discharging the resident: I came to work here February 2023. He had a PAS completed by the former SW on 12/01/21, he was not approved for nursing home care. Medicaid was not going to pay for his stay. We were talking with him about a place to live. He told me he needed a payee for his check so I contacted an agency that will be representative payee. I sent them the information but haven't heard back on the status. I called some places looking for an apartment for him but they were all full with long waiting lists. The SW provided notes of the above. She stated the homeless shelter was called on the day he left. I was told they had 1 bed but they don't put people on the waiting list. It's a first come first serve basis so we transported him to the shelter before the bed was no longer available. The SW denied notification of the ombudsman regarding the discharge. She said the resident was aware he was leaving on 04/17/23. She was unable to provide any formal notification the resident was told and provided a written discharge notice which included the reason for the discharge, where he would be discharged to, and when the discharge would occur. She said she told him medicaid would no longer pay for his stay and he didn't want to appeal this decision. In addition, the SW was unable to provide a written copy of a 30 day notice of discharge which is required to be provided to the Resident for a facility initiated discharge. The SW provided a Adult Protective Services Mandatory Reporting Form, dated 03/07/23 that included the resident's name birth date , address with the following: Describe physical/cognitive/emotional functioning of the alleged victim: Typed in was the notation: One prosthetic leg needs help with some ADL's (activities of daily living). Has Bipolar disorder and schizophrenia. No other information was on the form to indicate the Resident would be discharged and needed placement. An email was sent to the local Department of Health and Human Services, case worker on 05/08/23. The following was received from the case worker: I know that I had a homeless case open for him (referring to the Resident) and we were looking at placement in an apartment in (Name of a town) I was working on finding clothes and items needed for the apartment since he had nothing. I met with him one time and had contact with Social Worker at the facility about his needs or progress on the apartment matter. I was not informed he was dc (discharged ) until after it happened. They told me that (Name of Homeless Shelter) would be assisting him in locating an apartment and (Name of Nursing Home) would hold his items that we had gathered for him until he needs them. A telephone call to the homeless shelter supervisor revealed the following information on 05/09/23: We are a homeless shelter. People who come here have to take care of themselves. I can assure you no one told the nursing home we give medications or take care of residents. Residents can sleep here and go to a separate house for dining. We noticed the Resident was not eating. I ask him why and he said he could get from the sleeping area to another building for meals, he said it was just too far. I felt bad so we took him food on occasions. A few weeks after he was here, the Resident came to me with some pills in a baggy. He said he didn't know what he was supposed to take. Even if I could help him I had no information on how he should take the medication. We do not dispense medications or help in any way with ADL's. The Resident is currently at the hospital. On 05/06/23 at about 3:14 AM we called an ambulance for him because he was vomiting blood. We do help residents find housing but he didn't know how much money he receives or where his check was even going. He told me, If I need money, I go to the bank, I guess he was referring to the facility bank. When asked if an employee at the Homeless Shelter quoted in the 4/17/23 facility nurses note was available, the reply was, We have no one by that name that works here and no one here that has a name that sounds like like that name. Also the worker confirmed this resident has never been to this shelter before. The Director of Nursing (DON) was interviewed at 3:49 PM on 05/09/23. The DON confirmed the resident was transported to the shelter with the facility van and a driver. As the DON had made the late entry in the medical record, dated 04/17/23 at 12:30 PM she was asked who she spoke with at the shelter. She recited the name quoted in the note. The DON was advised no employee by that name works at the shelter and how could the resident say they had helped him before when he has never been to this homeless shelter. She stated maybe she misunderstood. The DON was asked to provide a care plan which entailed the Resident's discharge plans. She reviewed the care plan at the time of discharge and said it really doesn't have a whole lot of information about his discharge plans. The DON was asked why discharge planning was not started after the 5/19/22 PAS was completed because the facility would have know the Resident could only stay at the facility for up to 6 months. The DON said she really doesn't know because the Social Worker would have been working on that. At 5:30 PM on 05/09/23, the facility minimum data set coordinator Licensed Practical Nurse #103 reviewed the care plan and said there really isn't anything specific about him being discharged immediately. She stated she really wasn't aware the Resident was being discharged . The resident was reached by telephone with the assistance of a case manager at the current hospital on 05/10/23 at 2:24 PM. The Resident said, It made me uneasy when I got to the homeless shelter. I couldn't eat because my nerves were shot. My nerves were shot for going there. The Resident confirmed he did not know what medications he takes and he didn't know what to do with them when he got to the homeless shelter. The Resident said he would like to go to another nursing home when he leaves the hospital. The case manager and the Resident confirmed he was admitted to the hospital for an upper GI bleed. The case worker said she was in the process of completing a new PAS to see if he would qualify for a nursing home. She felt the Resident would not be able to live alone as confirmed by the Resident who doesn't think he can manage a home on his own. The case manager said the Resident was pleasant and cooperative and has not displayed any behaviors while at the hospital

Based on record review, Medical Power of Attorney (MPOA) interview, outside agency interview, and staff interview, the facility failed to allow a resident to return to the facility following a brief hospitalization . When the facility did not allow the resident to return, the facility failed to initiate a discharge and did not comply with transfer and discharge requirements at 42 CFR 483.15(c). This was true for one (1) of three (3) residents reviewed for admission/discharge. This deficient practice resulted in actual psychosocial harm to Resident #7. Resident identifier: #7. Facility census: 107. Findings included: a) Resident #7 An electronic medical record review, completed on 09/06/22 at 3:00 PM, revealed the following: -Resident #7 was admitted to the facility on [DATE] as a long-term care resident. -Resident #7 was diagnosed with Unspecified Dementia with Behavioral Disturbances and Post Traumatic Stress Disorder. -Resident #7 was transferred to the local hospital for evaluation on 08/29/21 following an incident where the resident had an altercation with a nursing assistant. -West Virginia Medicaid was Resident #7's payor source. -It was noted that a verbal Notice of Transfer was given to the resident's Medical Power of Attorney (MPOA) on 08/29/21. -The Discharge Minimum Data Set (MDS), dated [DATE], noted Discharge-return anticipated. -The medical record documentation ended on 08/29/21 and did not include any other details as to why Resident #7 did not return. During a telephone interview on 09/06/22 at 7:40 PM, Resident #7's Medical Power of Attorney (MPOA) reported the following details: -Resident #7 had lived at the facility for approximately three (3) months prior to his discharge to the hospital on 08/29/21. The MPOA reported Resident #7 had felt the facility was his home and it was a terrible experience for him and his family members when he was refused the right to return to the facility after he received medication management and stabilized. -The MPOA did not recall ever receiving a written Notice of Discharge including the right to appeal the decision of the facility to not readmit resident. -The MPOA reported that the former Admissions Director at the facility [who has since retired] had told her that her loved one could not return to the facility because he was a danger to other residents and to staff. She went on to report the former Admissions Director stated, We will pay the fine if it comes to it. -The MPOA stated Resident #7 remained at the inpatient psychiatric placement from 08/29/21 - 12/16/21 because of the facility's refusal to accept him back when he was ready to be released around 09/07/21. The MPOA stated that most admissions to the inpatient psychiatric placement never go beyond a 28-day period. However, the psychiatric placement found it very difficult to secure a long-term care nursing home placement for Resident #7 once the other facilities read his previous nursing home placement would not accept him back into their building. The MPOA emphasized that her loved one had stabilized and was not exhibiting behavioral problems when the facility refused to readmit him. The MPOA emphasized that over the course of the next three (3) months he remained behavior free and was just waiting for a long-term care nursing home placement. -Resident #7 ended up being placed approximately two (2) hours away from where his MPOA and other family members lived making it difficult for the family to visit him. Resident #7 passed away at the new facility on 01/15/22. During a telephone interview on 09/07/22 at 9:30 AM, the Social Worker at the geriatric inpatient psychiatric unit confirmed the allegation the facility refused to readmit Resident #7 when he was ready to be released. The Social Worker reported the attending physician had determined Resident #7 had stabilized and was not exhibiting any aggressive behaviors, was ready to be released, the necessary pre-admission screening paperwork had been completed and approved, and a telephone call had been made to the Admissions Director to schedule resident's return. At that time, the Admissions Director reported the facility would NOT take Resident #7 back at that they were OK with getting dinged for it. The Social Worker at the geriatric inpatient psychiatric unit confirmed Resident #7 remained on the unit for another three (3) months until she was successful in finding a placement approximately two (2) hours away from his MPOA and other family members. The Social Worker shared written documentation regarding the above-mentioned facts. The documentation was dated 09/07/21. During an interview with the Director of Nursing (DON) on 09/07/22 at 3:00 PM, the DON acknowledged Resident #7's medical record did not include any evidence of why the resident did not return to the facility. The DON reported, Safety of residents is always our top priority. She went on to report that a determination of a resident not returning to the facility would be made on a corporate level. When asked if the facility had made efforts to ascertain the current up-to-date status of Resident #7 when the geriatric inpatient psychiatric unit was ready to return resident to the facility or if the facility merely decided to not readmit the resident based on his condition when originally transferred to the hospital, the DON stated she would need to check with the new Admissions Director to determine if that office had a record of how the former Admissions Director [who has since retired] handled the situation. When asked if the facility could produce evidence Resident #7's MPOA and the long-term care Ombudsman was given a written Notice of Discharge including the right to appeal the decision, the DON stated she would need to check into it. During an interview on 09/07/22 at 3:40 PM, the Director of Social Services stated that from her recollection she thought the decision to not readmit Resident #7 stemmed from a decision made following conversations between the DON and the physicians at the facility who felt that the resident could not be successfully managed in the building. The Social Worker stated there was no written documentation she could provide; she was just going on her recollection of the situation. Resident #7 experienced actual psychosocial harm when we was held in an inpatient psychiatric hospital from 08/29/21 to 12/16/21 because of the facility's refusal to accept him back when he was ready to be released around 09/07/21. Resident #7 MPOA expressed the nursing home was his home and it was a terrible experience for him and his family members when he was refused the right to return to the facility after he received medication management and stabilized. The facility noted in the resident's medical record they anticipated the resident's return at the time of this discharge to the hospital on 08/29/21. Furthermore, Resident #7 experience actual psychosocial harm when he was forced to move to another nursing home two hours away from family. Resident #7 was not only harmed by the facility's refusal to readmit, but by the result of moving far away from family. The facility also expressed a lack of responsibility to readmit residents to their home after a hospital stay. This was evidence by the statement by the Admissions Director that, We will pay the fine if it comes to it. No further information was provided through the completion of the survey.

Based on observation, family interview, resident interview, record review, and staff interview, the facility failed to ensure a resident's environment remained as free of accident hazards as possible. The facility also failed to ensure the resident received adequate supervision and assistance devices to prevent accidents. The facility failed to securely attach a push call bell to a paralyzed resident's upper left shoulder which she could activate with her left face/chin when in need of assistance. In addition the facility failed to monitor the application of this device and identify the potential hazard. Resident identifier: #26. Facility census: 112. Findings include: a) Resident #26 During a family interview, on 08/11/15 at 12:00 p.m., Resident #26's husband voiced concerns that he often found his wife with her push call button pad out of reach. Because of her multiple sclerosis (MS), she had lost all body movement except her neck, and had swallowing difficulties and a history of choking. He stated on occasions he observed her covered in emesis with her airway obstructed and her call bell out of reach. Her push call pad button needed to be secured to her left shoulder so she could turn her head to the left and activate it with her chin/face. On 08/12/15 at 11:00 a.m., an observation of Resident #26, found the push call bell touch pad pinned to her chest, out of reach of her chin/left side of face. The resident attempted to activate the call pad from this location and was unsuccessful. The soft spoken resident tearfully reported that this happened frequently and she was unable to yell out for help. Her roommate frequently called the staff when she needed assistance. On 08/12/15 at 11:15 a.m., Assistant Director of Nursing (ADON) #156 verified the push call pad device was not secured in a position that the resident could activate with the left side of her face/chin. A follow up observation on 08/12/15 at 3:00 p.m., found the resident alert and alone in her room with the push call pad off of her shoulder and out of reach. Nurse Aide (NA) #39 acknowledged Resident #26 could not activate the push call pad from its current position and repositioned the device. Review of the medical record, on 08/12/15 at 2:30 p.m., revealed Resident #26 had capacity. Her [DIAGNOSES REDACTED]. She was paralyzed from the neck down secondary to the MS, had a history of [REDACTED]. An interview with the director of nursing and Assistant Director of Nursing (ADON) #156, on 08/12/15 at 3:30 p.m., verified this situation. The ADON stated, It is a given that call bells are to be in reach, and agreed this was not being done since the push call pad was found out of reach on two (2) separate occasions. During a random observation on 08/13/15, the push call pad button was again found out of reach in a position the resident could not activate. The facility administrator was immediately notified and actions were taken to secure the device further. In addition the facility ordered an alternative call system for the resident to activate with her breath.

Based on medical record review and staff interview, the facility did not obtain psychological / psychiatrics services for a [AGE] year old male resident (#107) who was exhibiting an escalation in behaviors towards other residents, visitors, and staff that were socially and sexually inappropriate, verbally abusive, and physically aggressive. Resident #107 frequently propelled his wheelchair backwards in the corridor, thereby creating a safety hazard for other residents. He also pushed an overbed table into the leg of his roommate, frequently engaged in unwanted physical contact of a sexual nature with female residents, staff, and visitors (when he would touch their buttocks, inner thighs, and/or breasts), verbally abused and physically struck female staff on the chest and buttocks, exposed his genitals to others, and repeatedly removed the incontinence brief and exposed the perineal area of a [AGE] year old cognitively impaired, totally dependent female resident. Medical record review found no evidence of current quantitative and/or qualitative tracking Resident #107's behaviors. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, occurring over a 100-day period, documenting socially and sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Record review found Resident #107 had been exhibiting sexually inappropriate behaviors for several years, for which he received evaluations on at least three (3) occasions since 2006. His last consult, with a neurologist on 07/14/08, identified concerns with tremors, urinary urgency, and sexually aggressive behaviors. The consulting physician recorded, "His behavior problem is not responding to SSRI's (selective serotonin reuptake inhibitors). I wonder if a medication such as [MEDICATION NAME] might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the [MEDICATION NAME] (medication to treat tremors). Follow-up can be arranged as needed." The resident's attending physician and the facility's interdisciplinary care team members were aware that Resident #107's behaviors were escalating. However, no follow-up psychological or psychiatric services were sought by the facility after the increase in frequency of behaviors was noted by staff. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. Documentation revealed Resident #107 displayed abusive and inappropriate behaviors towards at least four (4) identified residents (#108, #30, #110, and #14), and multiple unidentified residents, as well as multiple female staff members and visitors, and his behavior resulted in actual harm to a female activity staff member who sustained four (4) bruises on the left inner thigh after having been "grabbed" by him. Facility census: 106. Findings include: a) Resident #107 Medical record review, on 02/05/09 at 3:00 p.m., revealed Resident #107, prior to being discharged from the facility at 2:10 p.m. on 02/04/09, engaged in verbally abusive / physically aggressive and socially and sexually inappropriate behaviors towards other residents, female staff, and female visitors. Further review revealed the facility failed to implement interventions to protect residents, staff, and visitors from this resident's actions, even though Resident #107 had been exhibiting these behaviors for years. ---- 1. Record review revealed a [AGE] year old male was admitted to the facility from a rehabilitation hospital on [DATE], with [DIAGNOSES REDACTED]. A neuropsychological evaluation, dated 02/27/06, revealed the following: "(Resident #107) currently resides at Heartland of [MEDICATION NAME] County Nursing Home where he has lived for several years. He has had increasing behavior difficulties at the nursing home, particularly over the last 6 months. These involve inappropriate sexual touching of staff, other residents, and visitors. He is also described by nursing staff to masturbate frequently, perhaps several times per day. The staff has attempted to modify his behavior by providing objects for his hands, redirecting his attention, reprimanding him, and engaging him in activities. . . . With prompts, (Resident #107) was able to state the concerns regarding his behavior, but showed a lack of appreciation of their significance. . . . (Resident #107) demonstrates severe cognitive impairment secondary to his significant closed head injury. Particular deficits were noted in motor skills, memory, processing, and frontal lobe functions. The patient has some relatively preserved cognitive functioning, which makes it seems as if his behavior is willful. However, the results of this evaluation indicate that he lacks sufficient cognitive ability to fully appreciate his behavior and/or inhibit it. It is recommended that a structured program be developed in which appropriate behaviors are differentially reinforced. . . . In addition, it is suggested that staff be trained and the patient's environment be structured with the goal of limiting opportunities for inappropriate behavior. Re-referral to a psychiatrist, ideally a neuropsychiatrist, is strongly recommended to determine whether medication may be effective in minimizing the patient's libido and managing his behavior." A psychological consult, dated 05/08/06, contained the following recommendation: ". . . He currently displays a 'grasping reflex'. Any stimulation to the palm of the hand will engage a grabbing response. This may account for some of his 'inappropriate touching', as staff attempt to provide his care. He may benefit from grasping a substitute e.g. rolled washcloth, while care is being provided." A neurology consult, dated 07/14/08, revealed the following: ". . . He (Resident #107) is now on [MEDICATION NAME] 20 milligrams/day for behavioral problems. He has some sexual (sic) aggressive behaviors involving grabbing at the nursing staff and other clients. Reportedly the [MEDICATION NAME] is not working. . . . His behavior problem is not responding to SSRI's. I wonder if a medication such as [MEDICATION NAME] might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the [MEDICATION NAME] (medication to treat tremors). Follow-up can be arranged as needed." There was no evidence in Resident #107's medical record of efforts by the facility to obtain follow-up psychiatric and/or psychological services to address his sexually aggressive behaviors, after the 07/14/08 consult and prior to his discharge on 02/04/09. ---- 2. Review of Resident #107's medical record found no evidence of current quantitative and/or qualitative tracking of all of Resident #107's behaviors, although psychopharmacologic drug monthly flow records were completed for tracking the frequency at which Resident #107 was hitting, slamming doors, and intentionally backing his wheelchair into staff. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, over a 100-day period, documenting socially / sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. Sixty-nine (69) entries recorded Resident #107 grabbing female staff, residents, and/or visitors on their breasts, buttocks, and inner thighs. Eighteen (18) entries recorded Resident #107 appearing outside of his room with no clothing on, exposing his genitalia to others. Twenty-seven (27) entries recorded Resident #107 wheeling his wheelchair backwards, creating a safety hazard for others. Twenty-seven (27) entries recorded episodes of Resident #107 verbally abusing / being physically aggressive towards others, including staff, other residents, and visitors; one (1) of these episodes resulted in an activity staff member receiving four (4) bruises to the left inner thigh. Four (4) entries recorded Resident #107 removing the incontinence brief from a severely cognitively impaired [AGE] year old female resident (#108), who was totally dependent upon staff for her activities of daily living. Entries included: On 10/28/08 at 2:45 p.m., ". . . Grabbing @ staff's bottom saying 'I want it.' Res became aggressive & mad @ staff when redirected & told him it was inappropriate behavior. Res hit two staff members & told this writter (sic) that if I ran my mouth he'd hit me too. . . . Tried to grab another staff member's bottom as he went down the hall." On 10/29/08 at 6:30 p.m., ". . . Res (resident) inappropriately grabbed a female visitor awaiting trick or treating activity. Staff telling res that inappropriate behavior is not tolerated. Res going 'yea'." On 11/05/08 at 11:40 p.m., "Res tried to go into 400 hall main bathroom - alarm sounded. CNA's (certified nursing assistants) attempted to redirect res, whereupon res began yelling & hitting @ them. Res from room (number) was also in the hallway @ this x (time), mumbling to himself, which only made this res more upset. Res began yelling @ other man. . . ." On 11/20/08 at 8:00 p.m., "Res /c (with) behavior issues. Attempting to remove t-shirt while in dining room. Staff reporting Res became aggressive & went backwards in wc (wheelchair) spinning another res around in their wc. Notified nurse regarding other res to assess for any injuries. . . ." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 11/22/08 at 7:00 p.m., ". . . It was reported by roommate that he (Resident #107) pushed table into roommate (sic) leg & messing /c TV." On 12/03/08 at 6:45 p.m., "Res in room /c all clothes off, lying in bed, masturbating. CNA's pulled curtain around resident. Res angry, got (arrow pointing up) in w/c per self, hitting @ staff & kicking. Cursing at staff saying 'You whore & [***] '. Res begins to chase CNAs down hallway & cursing, backing one CNA into corner & hitting @ CNA. . . ." On 12/03/08 at 7:30 p.m., "Res returned to hallway. Into another female resident's room, female res yelling 'help me, help me.' Res in room uncovered other resident & was attempting to unfasten resident's wing (incontinence brief) & had hand over wing & thigh area. Res removed from room & states 'I was trying to help her to the BR.' . . ." (The female resident involved in this incident was Resident #108.) On 12/04/08 at 7:30 p.m., ". . . Res is grabbing at residents & staff. When redirected he gets verbally abusive & rams w/c into wall. When this writer explains to res that he can't do this (sic) his statement is 'I don't care.' . . ." On 12/05/08 at 8:30 a.m., "CNA went to let res know it was time for Breakfast. Res went to grab CNA. CNA stated 'Don't grab me.' Res then punched CNA in stomach. . . ." On 12/13/08 at 3:30 p.m., "Res wheeling self backward down hallway from room /c pants & underwear off. When res asked to get dressed, res laughing (sic) states 'I don't have too (sic).'. . ." On 12/17/08 at 6:00 a.m., "Res in female resident (sic) room, unfastened & opened res incontinence brief. When redirected to leave room & that it was inappropriate for him to be removing female resident (sic) clothes, (Resident #107) became agitated and attempted to back w/c into this writer. Removed from female (sic) room . . ." (The female resident involved in this incident was Resident #108.) On 12/20/08 at 4:40 a.m., "Called to floor by CNA's who had found resident again in female resident room. Res had unfastened female's incontinence brief and pulled it down, exposing female's peri-area. When resident told he needed to leave room & not enter again, he became agitated and telling this writer to 'shut up'. . . ." (The female resident involved in this incident was Resident #108.) On 12/20/08 at 1:00 p.m., "Res motivating (sic) w/c backward & yelling. This nurse tried to redirect, started asking him his multiplications. He then saw another res coming (sic) said 'I'm going to hit him in the damn head.' He then started for other res. Other res stepped out of way. This res cont. This nurse held w/c to keep him from running into other res. He then started hitting at this nurse. CNA came to help. Redirected res to cafe. Res then stripped off clothes. When ask (sic) why res stated to this nurse 'Your (sic) mean (sic) you didn't let me hit him.' This nurse explained 'I could not let that happen.' Res said 'You could have turned your head.' . . ." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 12/21/08 at 6:30 p.m., "Res found in female resident's room, had unfastened incontinence wing (brief), exposing resident. Res asked to leave room & that it is inappropriate to re-enter room. Cursing at staff. Wheeled self backwards & to room." (The female resident involved in this incident was Resident #108.) On 12/23/08 at 2:20 p.m., "Res going up hallway, Sally Ann's Dance girls, grabbing one of the dancers (sic) behind. Res redirected & taken to room." On 12/24/08 at 11:30 a.m., "Upon walking up 400 hall, CNA voiced that '(Resident #107) is in that room & won't come out.' Res did come out of room. When asked res to 'give me (other resident)'s stuff.' Res became very aggressive and hitting this writer. Asked res to stop and go back over to his own room, res repeatedly yelled, 'shut up', 'don't touch me.' No staff had touched res. Res pushed back to 100 hall. This writer walked past res approx(imately) 10 min(utes) later, res stated, 'Your ass is mine. I want your butt.' Told res to stop. Res voiced, 'no, I want your butt.' Unable to redirect res. . . ." On 12/28/08 at 6:30 p.m., "Res in w/c @ 4:15 p.m. motivating (sic) self backward. Ran w/c in to walker of another res, knocking it sideway (sic), Res stumbled, this nurse stopped res from falling. When redirected to (symbol for change) direction, Res grabbed this nurse by the arm, refusing to let go. Called for help & res released arm." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 01/04/09 at 3:30 p.m., ". . . (Arrow pointing up) in w/c (wheelchair) at present, going down hallway in w/c. Grabs another female resident by the breast & let go. When asked why he did that, res states while laughing 'because I want to.' . . ." (The female resident involved in this incident was Resident #30.) On 01/10/09 at 10:00 a.m., ". . . Wheeled self into hallway /c lower portion of body exposed. Staff assisted res in dressing & asked res to please not come out of room undressed. Res laughed. Grabbed several female staff this a.m. (morning) on the buttocks. When asked not to do this he smiles (sic) & and stated 'But I want to.' . . ." On 01/10/09 at 12:00 p.m., "Res grabbed a visitor's buttocks /s (without) permission. Res redirected by staff & staff apologized to visitor. Res also entered female res rooms (sic) this am (morning) while res dressing. Res removed from room and returned to his hall area and explained to (sic) that his behavior is unacceptable. Res states 'I don't care.'" On 01/11/09 at 2:00 a.m., "Res (arrow pointing up) in w/c (arrow pointing up) & (arrow pointing down) hallway - removing clothes & going nude. Very aggressive when assisted to put clothes back on. . . ." On 01/18/09 at 3:25 a.m., ". . . Propelling self backwards (arrow pointing up) & (arrow pointing down) hallway. Enc to turn & go forward for safety - res refused. Explained risk of running into walls, furniture, other people - Res states 'I won't.' Had near miss /c female resident who was ambulating in hallway. Conts /c grabbing @staff @times. . . ." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 01/19/09 at 3:35 a.m., "(Arrow pointing up) in w/c, frequently motivating (sic) self backwards. When asked to turn around, res becomes angry, states 'No! I don't want to' . . . In hallway /c bottom ? of body exposed. Redirected to room to dress." On 01/20/09 at 3:40 a.m., "Conts to propel self (arrow pointing up) hallway backwards. Attempts to redirect met /c aggression / swearing @ staff. Came (arrow pointing up) hallway /c bottom ? of body exposed. Asked to return to room to sleep or get clothes on. Res asked for assistance, then proceded (sic) to grope CNA repeatedly. Redirected /c res becoming verbally assaultive - calling staff '[***] es'. . . ." On 12/22/08 at 4:00 a.m., "Res in room (number) in bed #2. CNA (certified nursing assistant) awakened resident & told him to go to his own room/bed. Res got out of bed & into w/c. Grabbed CNA in chest and between legs. Redirected to inappropriateness of his actions. . . ." On 01/25/09 at 6:40 p.m., ". . . Grabbing staff inappropriately (sic). This writer redirected him numerous x's (times). Res even grabed (sic) another res inapproately (sic). Was told he was not allowed to touch another res. His comment was 'Why not.'. . ." (The female resident involved in this incident was Resident #14.) On 01/29/09 at 10:30 a.m., "Reported to this nurse by activities director, activity person was grabbed on 1/27/09 by this Res. Activity staff person has (4) small round bruises on (L) (left) inner thigh at area." On 01/30/09 at 10:00 p.m., "Res (arrow pointing up) in w/c hitting staff & grabbing visitors. Hit CNA in this chest & this writer in the buttocks. Res was redirected & told not to behave in such a manner. He said 'Come on [***] (sic) & tried to run into us with this wheelchair." On 02/02/09 at 8:30 p.m., "Res in main lobby attempting to go out front door. Keepsafe alarm sounding. Res hitting nurse & CNA's attempting to re-direct res from door. Standing & yelling 'Come on [***] !' Cursed at visitor & young daughter, states 'F-ck you!' Re-directed to room /p (after) 5-10 mins (minutes). Res conts to yell at CNA's. . . ." ---- 3. Review of Resident #107's physician progress notes [REDACTED]. On 07/15/08, "(Resident #107) is generally stable. His (responsible party) did not want the use of jumpsuit. . . . He was seen by the neurologist and it was noted that he had a tremor, [MEDICAL CONDITION] bladder and behavior problems. . . ." On 09/10/08, ". . . He has still been problematic with his aggressive sexual behavior here. Note from neurologist (from 07/14/08 consult) read regarding his tremor. . . . Also in regard to suggestion of [MEDICATION NAME] will try this in regard to his libido." On 10/15/08, ". . . No changes in regard to tremor or behavior." On 11/12/08, ". . . The same aggressive behavior still an issue here, especially among the female staff. . . . This pt (patient) will be transferred to services of Dr. (name). . . ." On 12/10/08, "(Resident #107) has a history of CHI (closed head injury) with secondary [DIAGNOSES REDACTED], dysarthria, gait disorder, sexual aggression, ? depression, overactive bladder and lately has been exhibiting some increasing aggression and inappropriate behavior including masturbating in front of anybody who may be around including children . . . History of CHI with increasing agitation and inappropriate behavior. We will continue his current meds but will also add on [MEDICATION NAME] 500 mg daily and monitor for affect (sic). . . ." On 01/05/09, ". . . At last evaluation he was seen for some increasing aggression and inappropriate behavior and had [MEDICATION NAME] added. There has been minimal improvement with this and he actually had an interaction with another resident, which may result in him being removed from this facility. . . . There is the potential that the pt will be removed from the facility later this mth (month) due to his behavior. . . ." ---- 4. Resident #107's social services progress notes recorded that Resident #107's behaviors, although chronic, were escalating. Although, medication adjustments were being made and (beginning in September 2008) the facility started exploring alternative placements for the resident, the resident's care plans were not revised when the interventions were found to be ineffective in controlling and/or reducing the resident's behaviors. ---- 5. During an interview on the afternoon of 02/10/09, the director of nursing (DON - Employee #5) identified that staff was to complete an incident /accident report when incidents resulted in resident injury; the DON reported Employee #21 was in charge of the incident / accident reports and additional questions would be needed directed to her. The DON also identified that the facility's administration did not believe Resident #107's behaviors were of a sexual nature (contrary to documentation found in nursing, social services, and physician progress notes [REDACTED]. When questioned about whether Resident #107 had received services from a mental health professional to address this increase in behaviors, since the resident's medical record revealed the last time he received the services of a psychologist was in 2006, the DON reviewed his record. Shortly thereafter, the DON acknowledged the facility did not refer Resident #107 for psychological or psychiatric services when he exhibited an increased frequency of behaviors at the end of October 2008. .

Based on medical record review and staff interview, the facility did not provide adequate supervision to prevent a [AGE] year old male resident (#107) from being socially and sexually inappropriate, verbally abusive, and physically aggressive towards staff, other residents, and visitors. Resident #107 frequently propelled his wheelchair backwards in the corridor, thereby creating a safety hazard for other residents. He also pushed an overbed table into the leg of his roommate, frequently engaged in unwanted physical contact of a sexual nature with female residents, staff, and visitors (when he would touch their buttocks, inner thighs, and/or breasts), verbally abused and physically struck female staff on the chest and buttocks, exposed his genitals to others, and repeatedly removed the incontinence brief and exposed the perineal area of a [AGE] year old cognitively impaired, totally dependent female resident. Medical record review found no evidence of current quantitative and/or qualitative tracking Resident #107's behaviors. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, occurring over a 100-day period, documenting socially and sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Record review found Resident #107 had been exhibiting sexually inappropriate behaviors for several years, for which he received evaluations on at least three (3) occasions since 2006. His last consult, with a neurologist on 07/14/08, identified concerns with tremors, urinary urgency, and sexually aggressive behaviors. The consulting physician recorded, "His behavior problem is not responding to SSRI's (selective serotonin reuptake inhibitors). I wonder if a medication such as Proscar might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the Primidone (medication to treat tremors). Follow-up can be arranged as needed." The resident's attending physician and the facility's interdisciplinary care team members were aware that Resident #107's behaviors were escalating. However, no follow-up psychological or psychiatric services were sought by the facility after the increase in frequency of behaviors was noted by staff. Although the resident's medication regimen was periodically adjusted to address his behaviors, review of his care plans for "inappropriate touching", physical and verbal aggression, "inappropriate dressing", and wheeling his wheelchair backwards revealed the goals were not always realistic and/or measurable, and the interventions were not revised when it should have been evident to the interdisciplinary care team, based on the numerous entries in the nursing notes from October 2008 to the date of the resident's discharge on 02/04/09, that the interventions were not effective in achieving the stated goals. Although the facility, according to social service progress notes beginning in 09/18/08, identified the need for alternative placement for this very young resident with sexually aggressive behaviors, none of the care plans included providing increased supervision to protect other residents, staff, and visitors from Resident #107's behaviors until such alternative placement could be found. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. Documentation revealed Resident #107 displayed abusive and inappropriate behaviors towards at least four (4) identified residents (#108, #30, #110, and #14), and multiple unidentified residents, as well as multiple female staff members and visitors, and his behavior resulted in actual harm to a female activity staff member who sustained four (4) bruises on the left inner thigh after having been "grabbed" by him. Facility census: 106. Findings include: a) Resident #107 Medical record review, on 02/05/09 at 3:00 p.m., revealed Resident #107, prior to being discharged from the facility at 2:10 p.m. on 02/04/09, engaged in verbally abusive / physically aggressive and socially and sexually inappropriate behaviors towards other residents, female staff, and female visitors. Further review revealed the facility failed to implement interventions to protect residents, staff, and visitors from this resident's actions, even though Resident #107 had been exhibiting these behaviors for years. ---- 1. Record review revealed a [AGE] year old male was admitted to the facility from a rehabilitation hospital on [DATE], with [DIAGNOSES REDACTED]. A neuropsychological evaluation, dated 02/27/06, revealed the following: "(Resident #107) currently resides at Heartland of Preston County Nursing Home where he has lived for several years. He has had increasing behavior difficulties at the nursing home, particularly over the last 6 months. These involve inappropriate sexual touching of staff, other residents, and visitors. He is also described by nursing staff to masturbate frequently, perhaps several times per day. The staff has attempted to modify his behavior by providing objects for his hands, redirecting his attention, reprimanding him, and engaging him in activities. . . . With prompts, (Resident #107) was able to state the concerns regarding his behavior, but showed a lack of appreciation of their significance. . . . (Resident #107) demonstrates severe cognitive impairment secondary to his significant closed head injury. Particular deficits were noted in motor skills, memory, processing, and frontal lobe functions. The patient has some relatively preserved cognitive functioning, which makes it seems as if his behavior is willful. However, the results of this evaluation indicate that he lacks sufficient cognitive ability to fully appreciate his behavior and/or inhibit it. It is recommended that a structured program be developed in which appropriate behaviors are differentially reinforced. . . . In addition, it is suggested that staff be trained and the patient's environment be structured with the goal of limiting opportunities for inappropriate behavior. Re-referral to a psychiatrist, ideally a neuropsychiatrist, is strongly recommended to determine whether medication may be effective in minimizing the patient's libido and managing his behavior." A psychological consult, dated 05/08/06, contained the following recommendation: ". . . He currently displays a 'grasping reflex'. Any stimulation to the palm of the hand will engage a grabbing response. This may account for some of his 'inappropriate touching', as staff attempt to provide his care. He may benefit from grasping a substitute e.g. rolled washcloth, while care is being provided." A neurology consult, dated 07/14/08, revealed the following: ". . . He (Resident #107) is now on Paxil 20 milligrams/day for behavioral problems. He has some sexual (sic) aggressive behaviors involving grabbing at the nursing staff and other clients. Reportedly the Paxil is not working. . . . His behavior problem is not responding to SSRI's. I wonder if a medication such as Proscar might help reduce his libido to a more controllable level. We can focus on the tremor initially and left (sic) me know how he responds to the Primidone (medication to treat tremors). Follow-up can be arranged as needed." There was no evidence in Resident #107's medical record of efforts by the facility to obtain follow-up psychiatric and/or psychological services to address his sexually aggressive behaviors, after the 07/14/08 consult and prior to his discharge on 02/04/09. ---- 2. Review of Resident #107's medical record found no evidence of current quantitative and/or qualitative tracking of all of Resident #107's behaviors, although psychopharmacologic drug monthly flow records were completed for tracking the frequency at which Resident #107 was hitting, slamming doors, and intentionally backing his wheelchair into staff. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, over a 100-day period, documenting socially / sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Because of a lack of consistent qualitative and quantitative tracking of Resident #107's various behaviors, the extent to which other residents, staff, and visitors were affected by these behaviors could not be ascertained. --- Sixty-nine (69) entries recorded Resident #107 grabbing female staff, residents, and/or visitors on their breasts, buttocks, and inner thighs. Examples of these entries include: On 10/29/08 at 6:30 p.m., ". . . Res (resident) inappropriately grabbed a female visitor awaiting trick or treating activity. Staff telling res that inappropriate behavior is not tolerated. Res going 'yea'." On 12/22/08 at 4:00 a.m., "Res in room (number) in bed #2. CNA (certified nursing assistant) awakened resident & told him to go to his own room/bed. Res got out of bed & into w/c. Grabbed CNA in chest and between legs. Redirected to inappropriateness of his actions. . . ." On 12/23/08 at 2:20 p.m., "Res going up hallway, Sally Ann's Dance girls, grabbing one of the dancers (sic) behind. Res redirected & taken to room." On 01/04/09 at 3:30 p.m., ". . . (Arrow pointing up) in w/c (wheelchair) at present, going down hallway in w/c. Grabs another female resident by the breast & let go. When asked why he did that, res states while laughing 'because I want to.' . . ." (The female resident involved in this incident was Resident #30.) On 01/10/09 at 12:00 p.m., "Res grabbed a visitor's buttocks /s (without) permission. Res redirected by staff & staff apologized to visitor. Res also entered female res rooms (sic) this am (morning) while res dressing. Res removed from room and returned to his hall area and explained to (sic) that his behavior is unacceptable. Res states 'I don't care.'" On 01/10/09 at 7:40 p.m., "Res repeatedly unzipped pants asking asking (sic) staff to zip them now. Res entered soil (sic) utility room grabbing laundry person." On 01/14/09 at 4:00 a.m., ". . . Conts (continues) to grab @ staff @ times. Re-directed, res just grins @ staff and reaches for staff again. . . ." On 01/25/09 at 6:40 p.m., ". . . Grabbing staff inappropriately (sic). This writer redirected him numerous x's (times). Res even grabed (sic) another res inapproately (sic). Was told he was not allowed to touch another res. His comment was 'Why not.'. . ." (The female resident involved in this incident was Resident #14.) On 01/29/09 at 10:30 a.m., "Reported to this nurse by activities director, activity person was grabbed on 1/27/09 by this Res. Activity staff person has (4) small round bruises on (L) (left) inner thigh at area." --- Eighteen (18) entries recorded Resident #107 appearing outside of his room with no clothing on, exposing his genitalia to others. Examples of these entries include: On 12/13/08 at 3:30 p.m., "Res wheeling self backward down hallway from room /c pants & underwear off. When res asked to get dressed, res laughing (sic) states 'I don't have too (sic).'. . ." On 01/10/09 at 10:00 a.m., ". . . Wheeled self into hallway /c lower portion of body exposed. Staff assisted res in dressing & asked res to please not come out of room undressed. Res laughed. Grabbed several female staff this a.m. (morning) on the buttocks. When asked not to do this he smiles (sic) & and stated 'But I want to.' . . ." On 01/11/09 at 2:00 a.m., "Res (arrow pointing up) in w/c (arrow pointing up) & (arrow pointing down) hallway - removing clothes & going nude. Very aggressive when assisted to put clothes back on. . . ." On 01/19/09 at 3:35 a.m., "(Arrow pointing up) in w/c, frequently motivating (sic) self backwards. When asked to turn around, res becomes angry, states 'No! I don't want to' . . . In hallway /c bottom ? of body exposed. Redirected to room to dress." --- Twenty-seven (27) entries recorded Resident #107 wheeling his wheelchair backwards, creating a safety hazard for others. Examples of these entries include: On 11/20/08 at 8:00 p.m., "Res /c (with) behavior issues. Attempting to remove t-shirt while in dining room. Staff reporting Res became aggressive & went backwards in wc (wheelchair) spinning another res around in their wc. Notified nurse regarding other res to assess for any injuries. . . ." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 12/28/08 at 6:30 p.m., "Res in w/c @ 4:15 p.m. motivating (sic) self backward. Ran w/c in to walker of another res, knocking it sideway (sic), Res stumbled, this nurse stopped res from falling. When redirected to (symbol for change) direction, Res grabbed this nurse by the arm, refusing to let go. Called for help & res released arm." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 01/18/09 at 3:25 a.m., ". . . Propelling self backwards (arrow pointing up) & (arrow pointing down) hallway. Enc to turn & go forward for safety - res refused. Explained risk of running into walls, furniture, other people - Res states 'I won't.' Had near miss /c female resident who was ambulating in hallway. Conts /c grabbing @staff @times. . . ." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) --- Twenty-seven (27) entries recorded episodes of Resident #107 verbally abusing / being physically aggressive towards others, including staff, other residents, and visitors. Examples of these entries include: On 10/28/08 at 2:45 p.m., ". . . Grabbing @ staff's bottom saying 'I want it.' Res became aggressive & mad @ staff when redirected & told him it was inappropriate behavior. Res hit two staff members & told this writter (sic) that if I ran my mouth he'd hit me too. . . . Tried to grab another staff member's bottom as he went down the hall." On 11/05/08 at 11:40 p.m., "Res tried to go into 400 hall main bathroom - alarm sounded. CNA's (certified nursing assistants) attempted to redirect res, whereupon res began yelling & hitting @ them. Res from room (number) was also in the hallway @ this x (time), mumbling to himself, which only made this res more upset. Res began yelling @ other man. . . ." On 11/22/08 at 7:00 p.m., ". . . It was reported by roommate that he (Resident #107) pushed table into roommate (sic) leg & messing /c TV." On 12/03/08 at 6:45 p.m., "Res in room /c all clothes off, lying in bed, masturbating. CNA's pulled curtain around resident. Res angry, got (arrow pointing up) in w/c per self, hitting @ staff & kicking. Cursing at staff saying 'You whore & [***] '. Res begins to chase CNAs down hallway & cursing, backing one CNA into corner & hitting @ CNA. . . ." On 12/04/08 at 7:30 p.m., ". . . Res is grabbing at residents & staff. When redirected he gets verbally abusive & rams w/c into wall. When this writer explains to res that he can't do this (sic) his statement is 'I don't care.' . . ." On 12/05/08 at 8:30 a.m., "CNA went to let res know it was time for Breakfast. Res went to grab CNA. CNA stated 'Don't grab me.' Res then punched CNA in stomach. . . ." On 12/20/08 at 1:00 p.m., "Res motivating (sic) w/c backward & yelling. This nurse tried to redirect, started asking him his multiplications. He then saw another res coming (sic) said 'I'm going to hit him in the damn head.' He then started for other res. Other res stepped out of way. This res cont. This nurse held w/c to keep him from running into other res. He then started hitting at this nurse. CNA came to help. Redirected res to cafe. Res then stripped off clothes. When ask (sic) why res stated to this nurse 'Your (sic) mean (sic) you didn't let me hit him.' This nurse explained 'I could not let that happen.' Res said 'You could have turned your head.' . . ." (There was no incident report for this event; the identity of the other resident involved could not be ascertained.) On 12/24/08 at 11:30 a.m., "Upon walking up 400 hall, CNA voiced that '(Resident #107) is in that room & won't come out.' Res did come out of room. When asked res to 'give me (other resident)'s stuff.' Res became very aggressive and hitting this writer. Asked res to stop and go back over to his own room, res repeatedly yelled, 'shut up', 'don't touch me.' No staff had touched res. Res pushed back to 100 hall. This writer walked past res approx(imately) 10 min(utes) later, res stated, 'Your ass is mine. I want your butt.' Told res to stop. Res voiced, 'no, I want your butt.' Unable to redirect res. . . ." On 01/20/09 at 3:40 a.m., "Conts to propel self (arrow pointing up) hallway backwards. Attempts to redirect met /c aggression / swearing @ staff. Came (arrow pointing up) hallway /c bottom ? of body exposed. Asked to return to room to sleep or get clothes on. Res asked for assistance, then proceded (sic) to grope CNA repeatedly. Redirected /c res becoming verbally assaultive - calling staff '[***] es'. . . ." On 01/30/09 at 10:00 p.m., "Res (arrow pointing up) in w/c hitting staff & grabbing visitors. Hit CNA in this chest & this writer in the buttocks. Res was redirected & told not to behave in such a manner. He said 'Come on [***] (sic) & tried to run into us with this wheelchair." On 02/02/09 at 8:30 p.m., "Res in main lobby attempting to go out front door. Keepsafe alarm sounding. Res hitting nurse & CNA's attempting to re-direct res from door. Standing & yelling 'Come on [***] !' Cursed at visitor & young daughter, states 'F-ck you!' Re-directed to room /p (after) 5-10 mins (minutes). Res conts to yell at CNA's. . . ." --- Four (4) entries recorded Resident #107 removing the incontinence brief from a severely cognitively impaired [AGE] year old female resident (#108), who was totally dependent upon staff for her activities of daily living. On 12/03/08 at 7:30 p.m., "Res returned to hallway. Into another female resident's room, female res yelling 'help me, help me.' Res in room uncovered other resident & was attempting to unfasten resident's wing (incontinence brief) & had hand over wing & thigh area. Res removed from room & states 'I was trying to help her to the BR.' . . ." On 12/17/08 at 6:00 a.m., "Res in female resident (sic) room, unfastened & opened res incontinence brief. When redirected to leave room & that it was inappropriate for him to be removing female resident (sic) clothes, (Resident #107) became agitated and attempted to back w/c into this writer. Removed from female (sic) room . . ." On 12/20/08 at 4:40 a.m., "Called to floor by CNA's who had found resident again in female resident room. Res had unfastened female's incontinence brief and pulled it down, exposing female's peri-area. When resident told he needed to leave room & not enter again, he became agitated and telling this writer to 'shut up'. . . ." On 12/21/08 at 6:30 p.m., "Res found in female resident's room, had unfastened incontinence wing (brief), exposing resident. Res asked to leave room & that it is inappropriate to re-enter room. Cursing at staff. Wheeled self backwards & to room." (Note that Resident #108 was discharged from the facility on 01/06/09.) ---- 3. Review of Resident #107's physician progress notes [REDACTED]. On 12/17/07, ". . . There have been no acute episodes although his behavior is not any better. . . ." On 01/16/08, ". . . His behavior however has not improved. . . ." On 02/13/08, ". . . His behavior is about the same. . . ." On 05/15/08, " . . His behaviors are not improved. . . ." On 06/13/08, "I have an extensive conversation with (Resident #107's responsible party). There have been some behavioral problems in regard to exposing himself and also with smearing feces. . . . A jumpsuit has been ordered and the use of this and timing were discussed. . . ." On 07/15/08, "(Resident #107) is generally stable. His (responsible party) did not want the use of jumpsuit. . . . He was seen by the neurologist and it was noted that he had a tremor, neurogenic bladder and behavior problems. . . ." On 09/10/08, ". . . He has still been problematic with his aggressive sexual behavior here. Note from neurologist (from 07/14/08 consult) read regarding his tremor. . . . Also in regard to suggestion of Proscar will try this in regard to his libido." On 10/15/08, ". . . No changes in regard to tremor or behavior." On 11/12/08, ". . . The same aggressive behavior still an issue here, especially among the female staff. . . . This pt (patient) will be transferred to services of Dr. (name). . . ." On 12/10/08, "(Resident #107) has a history of CHI (closed head injury) with secondary [DIAGNOSES REDACTED], dysarthria, gait disorder, sexual aggression, ? depression, overactive bladder and lately has been exhibiting some increasing aggression and inappropriate behavior including masturbating in front of anybody who may be around including children . . . History of CHI with increasing agitation and inappropriate behavior. We will continue his current meds but will also add on Depakote 500 mg daily and monitor for affect (sic). . . ." On 01/05/09, ". . . At last evaluation he was seen for some increasing aggression and inappropriate behavior and had Depakote added. There has been minimal improvement with this and he actually had an interaction with another resident, which may result in him being removed from this facility. . . . There is the potential that the pt will be removed from the facility later this mth (month) due to his behavior. . . ." ---- 4. Resident #107's social services progress notes recorded that Resident #107's behaviors, although chronic, were escalating. Although, medication adjustments were being made and (beginning in September 2008) the facility started exploring alternative placements for the resident, the resident's care plans were not revised when the interventions were found to be ineffective in controlling and/or reducing the resident's behaviors. Examples of entries include: On 12/20/07, ". . . he has been displaying the following behavior problems: exit seeking (he is in the Exit (sic) seeking program & has orders for a secure care bracelet), resisting care (refusing medications - stating 'I don't want it') and socially inappropriate behavior AEB (as evidence by) defacating (sic) in his bed & then eating the feces. Care plans for these problems have been developed, revised, and/or continued. Res has not shown the following behavior problems during this assessment period. However, the care plans will be continued @ least until next review: (1) taking things that don't belong to him (ex. food), inappropriate dressing AEB being naked in public area, physical aggression d/t wheeling backward when upset (Res hit someone while doing this previously), and inappropriate sexual behavior as evidenced by grabbing or touching others on private areas of their bodies. . . ." On 03/20/08, ". . . Resident has Behavior (sic) problems i (1) episode of verbal abuse to staff (sic) ii (2) episodes of lacking clothes off & Being (sic) in hallway naked. . . ." On 04/07/08, ". . . Apparently, Res was in his room /c the door closed during the (fire) drill. A CNA went down the hallway opening Resident's (sic) doors. She opened (Resident #107)'s door & he allegedly slammed it shut on her fingers & toe which caused minor injuries. . . ." On 06/20/08, ". . . He continues to have other behaviors such as grabbing other individuals on inappropriate areas of their bodies, yelling @ staff, hitting @ staff, refusing medications, & wheeling his w/c backwards. . . ." On 09/18/08, ". . . Res is still exhibiting several behavior problems that include: exit seeking, physically & verbally abusive, going backward in his w/c, coming out into public areas /c 0 (no) pants on, touching / grabbing others inappropriately & refusing medications. . . This writer spoke with Res about all of these behaviors. He denied being physically abusive to staff. Otherwise, he had no explanation for the remaining behaviors. MD did order Proscar 5 mg q (every) day for (arrow pointing up)'d libido. . . ." On 12/12/08, "This writer was on telephone /c a family member when Res came into office unnoticed a (sic) grabbed this writer around waist / stomach area from behind. This writer attempted to push his arm / hand away. When I finally got him to remove his arm, I turned around & he had his arm raised, hand balled in a fist, as if he were going to punch this writer. However, he did not. . . ." On 12/18/08, "Resident's behavior seems to have been escalating over the last couple of months. Behaviors include: verbally abusive behavior (cursing @ staff), physically abusive behavior (hitting & punching staff, chasing staff, running into other /c w/c while going backward), socially inappropriate / disruptive behavior (slamming doors, going into other residents' rooms, removing his clothing in public, attempting to fondle female Resident & grabbing others on inappropriate areas of their bodies (sic), and resisting care (refusing meds). . . . MD did order Proscar for (arrow pointing up) libido but this does not appear effective. On 12/10/08, MD ordered 500 mg q day for CHI /c behaviors." On 12/18/08, "Late entry for 11/25/08. Res moved to room (number). Will monitor for any adjustment problems." On 12/18/08, "This writer has talked to Res about his new room a couple x's (times) & he has stated that he likes it. Res is having behaviors problems - but these are chronic & started escalating prior to his move." On 12/22/08, "(Resident's responsible party) (sic) in person @ facility. Res behaviors were explained to her & that they are now not only affecting staff but other residents as well. She agreed to work /c us on a transfer to a more appropriate facility. . . (Resident's responsible party) will look over info from other facilities & we will proceed /c any other referrals per her request. NHA (nursing home administrator) did explain that facility was going to issue a d/c (discharge) notice. (Responsible party) was understanding. . ." On 01/02/09, "(Resident #107)'s roommate requested a rm (room) (symbol for change) stating he could not be in room /c (Resident #107) for one more day d/t behaviors. Roommate to be moved this evening." On 02/04/09, "Res transferred to (area hospital) in hopes of admission to (area in-patient psychiatric facility) for behavioral eval. His Depakote was d/c'd (discontinued) d/t (arrow pointing up) liver enzymes & this may present a problem." ---- 5. During an interview on the afternoon of 02/10/09, the director of nursing (DON - Employee #5) identified that staff was to complete an incident /accident report when incidents resulted in resident injury; the DON reported Employee #21 was in charge of the incident / accident reports and additional questions would be needed directed to her. The DON also identified that the facility's administration did not believe Resident #107's behaviors were of a sexual nature (contrary to documentation found in nursing, social services, and physician progress notes [REDACTED]. When questioned about whether Resident #107 had received services from a mental health professional to address this increase in behaviors, since the resident's medical record revealed the last time he received the services of a psychologist was in 2006, the DON reviewed his record. Shortly thereafter, the DON acknowledged the facility did not refer Resident #107 for psychological or psychiatric services when he exhibited an increased frequency of behaviors at the end of October 2008. During an interview on the morning of 02/12/09, the director of care delivery (Employee #21) confirmed that incident / accident reports were completed on incidents resulting in resident injuries. However, no incident / accident reports were completed for the occurrences referenced above, nor was the frequency of these occurrences (verbally abusive / physically aggressive and/or socially and sexually inappropriate behaviors) being tracked in any way. (See citation at N362 for non-compliance with the State licensure rule, for failing to complete written reports for incidents / accidents involving residents either inside or outside of the nursing home.) ---- 6. Review of the resident's nursing notes revealed that, when Resident #107 exhibited these behaviors, staff responded by attempting to "redirect" him and informing him that his behaviors were "inappropriate". As evidenced by the frequent recurrence of the behaviors, these interventions were ineffective. Review of his care plan revealed a plan to address "inappropriate touching behavior" which was initiated on 12/19/06. The goal for this problem ("Reduced incidents of inappropriate sexual behavior thru next care plan review") was initiated on 12/19/06 and remained unchanged through present date; this goal was not measurable, as the facility failed to establish a baseline frequency for this behavior and failed to quantitatively and qualitatively document when Resident #107 exhibited this behavior. The interventions to achieve this goal remained essentially unchanged since revised on 12/18/08, although two (2) interventions were revised on 02/05/09, the day after he was discharged from the facility. Documentation in the nursing notes, from December 2008 through his date of discharge on 02/04/09, revealed he engaged in this behavior multiple times weekly, even multiple times daily, yet these interventions were not reviewed and revised when it should have been evident to the interdisciplinary care team that they were not effective. Review of his care plan revealed a plan to address physical and verbal aggression ("Physical and verbal aggression (hitting, punching, cursing at others {sic} (usually staff) and slamming doors related to: closed head injury."), which was initiated on 06/19/07. The goals for this problem ("Will not harm self or others during periods of physical aggression" and "Will not verbally abuse others") were initiated on 06/19/07 and remained unchanged since that date. The interventions were last revised on 09/19/08. Documentation in the nursing notes, from October 2008 through his date of discharge on 02/04/09, revealed he engaged in this behaviors multiple times weekly, sometimes multiple times daily, yet these interventions were not reviewed and revised when it should have been evident to the interdisciplinary care team that they were not effective. Review of his care plan revealed a plan to address "wheeling his wheelchair backwards into other individuals", which was initiated n 06/20/08. The goal for this problem ("Resident will wheel himself forward in his wheelchair.") was initiated on 06/20/08 and remained unchanged since that date. The interventions were last revised on 06/20/08, and consisted of the following: "Notify physician of behaviors as necessary. Ask resident nicely to turn his wheelchair around. Explain to resident in simple terms that he could hurt someone d/t (due to) not being able to see where he is going. Don't lecture Resident (sic). Present resolution of turning wheelchair around as a huge favor to you." Documentation in the nursing notes, from October 2008 through his date of discharge on 02/04/09, revealed he engaged in this behaviors multiple times weekly, yet these interventions were not reviewed and revised when it should have been evident to the interdisciplinary care team that they were not effective. Review of his care plan revealed a plan to address "inappropriate dressing (being in public area without appropriate clothing on)", which was initiated on 09/17/07. The goal for this problem ("Will have neat and