Health inspection·November 9, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate discharge information was documented in the medical record by the physician for one (Resident #1) of two residents reviewed for discharges. The facility failed to ensure documentation was made by the physician for the basis of Resident #1's discharge and/or the specific resident needs that could not be met by the facility. This failure could place residents at risk of being discharged without a safe and effective transition of care, an accurate reason for discharge and inaccurate information communicated to the receiving health care institution or provider. Findings included: Record review of Resident #1's undated Face sheet reflected she was an [AGE] year-old female with an original admission date of 03/01/21. Record review of Resident #1's discharge MDS assessment dated [DATE] reflected an unplanned discharge on [DATE] to a general hospital with anticipation of return to the facility. Record review of Resident #1's MDS Significant change assessment dated [DATE] reflected Resident #1 usually was able to make herself understood and usually understood other. Residents #1 had a BIMS of 1 which indicated she was severely cognitively impaired and indicated the resident had disorganized thinking which was continuously present and did not fluctuate. Resident #1 was not able to participate in the mood assessment interview. The staff assessment of Resident #1's mood indicted resident was short-tempered and easily annoyed 2-6 days in the last 2 weeks. Resident #1's behavior assessment indicated delusions, physical behaviors towards other, verbal behaviors towards others and other behaviors such as disrobing in public had occurred one to three days. Impact of resident's behaviors had significantly interfered with resident's care and had put others at significant risk for physical injury, had significantly intruded on the privacy or activity of others and had significantly disrupted care or living environment 1-3 days. Change in behaviors had worsened. Resident #1's active diagnoses included anxiety disorder, depression, non-Alzheimer's dementia, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder) and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident #1's care plan revised on 09/28/23 reflected, 04/19/23 Resident #1 has a history of rolling her wheelchair into another patient's wheelchair and pushing them to the wall and began Page 1 of 3 455563 455563 11/09/2023 Denison Nursing and Rehab 601 E Hwy 69 Denison, TX 75021

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hitting and scratching at other patient's face and neck .03/28/23 Threw a soda at another resident .Resident was very agitated and was physically aggressive and broke her window glass. She had no injury to self .Goal-The resident will not harm self or others through the review period .Interventions .Administer ABH gel (used to treat mild to moderate aggressive behaviors) as last resort as ordered .Frequent monitoring of resident .Notify son of inappropriate behaviors .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . Record Review of the Provider Investigation report submitted to HHS on 10/12/23 reflected, on 10/11/23 around 8:00 p.m. Resident #1 approached Resident #2 two different times with hands raised and screaming at him with offensive language. Resident #1 was removed from Resident #2 and then began beating on the glass of the front door. Police were called and EMS. EMS attempted to calm resident without success. Resident #1 was transported to local hospital. Resident #2 was returned to his room and assessed for injury. No injury found. Physician, Family, DON, and Administrator were notified. On 10/12/23 the hospital was notified that due to safety reasons the facility would not be accepting Resident #1 back to the facility. Facility notified Ombudsman and family. Facility faxed and certified mailed an immediate Discharge letter to family. Review of Resident #1's Immediate discharge letter dated 10/12/23 addressed to Resident #1's responsible party, reflected, This is to inform you that Resident #1 is being discharged from this facility immediately from the date of this letter 10/12/23. The reason for discharge, in accordance with federal regulations, is as follow .the safety of individuals in the facility is endangered . The letter provided the Responsible party the information for their right to appeal, the name, address and phone number of the Ombudsman and the toll-free number of the State Long Term Care Ombudsman. Review of Resident #1's Progress note by LVN A on 10/11/23: 7:40 p.m. Resident up at nurses' station in her WC, male resident walked by, and resident became belligerent, screaming at resident that he is creepy repetitively. This nurse attempted to redirect or distract resident, asked her to please be nice, without positive effect. Resident began screaming very loud you're a bitch repeatedly over and over at this nurse and flailing her arms and leg. CNAs unable to console resident. A different male resident was able to escort resident to smoke porch for fresh air and calm her down . 9:53 p.m. Resident has begun to go door to door in facility and beating, kicking glass. Resident states she wants out. Unable to redirect her anger. Resident continues to be aggressive with male resident and pursue him in hallway. This nurse and CNAs able to get male resident in his room and settled in bed at this time. Resident continues to be verbally abusive and aggressive with staff, hitting nurse when I walked by in hallway. DON and MD notified; resident sent to ER for evaluation. Resident has been refusing her medications, will not take antibiotic for her chronic UTI. Report called to ER . 10:45 p.m. Resident in hallway by back door sitting her WC, screaming, and cursing at staff. Staff monitoring resident location related to concerns for her safety. Staff at a distance to attempt to not aggravate resident current mental status. 911 notified of need to transport to ER for further evaluation and TX. When EMS and police arrived, resident continued to escalate, began hitting, kicking, and biting at EMS staff and police officer. Resident transported via stretcher to ER. Report called to RP, Hospice, Administrator, MD, and DON aware of transport . 455563 Page 2 of 3 455563 11/09/2023 Denison Nursing and Rehab 601 E Hwy 69 Denison, TX 75021

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #1' clinical records revealed there was no physician's documentation related to the basis for the discharge, specific resident needs that could not be met by the facility, attempts to meet the resident's needs and/or services that would be available at the receiving facility to meet the resident's needs. Interview with the Administrator on 11/08/23 at 10:40 p.m. he stated he had been at the facility since June 2023. He stated Resident #1 was in the hospital when he first started. He stated she had been hospitalized twice since then due to increased behaviors and since started targeting two of the residents in the facility. He stated they had attempted to have a care plan conference in September with the resident, the RP, and the ombudsman, but stated the RP and the resident refuse any of the recommendations made by the psychiatrist to help with the management of the resident's behaviors, and the RP insisted all her behaviors are related to her chronic UTI's. He stated they had an order for prophylactic antibiotics, but the resident refused to take medications 90% of the time. He stated there was no resolution accomplished during the care plan meeting. He stated he had to consider the safety of all the residents and felt they were not able to accomplish that as long as Resident #1 remained in the facility. He stated he determined an immediate discharge was warranted. In an interview with the DON on 11/09/23 at 10:00 a.m. she stated Resident #1's MD had agreed verbally to the immediate discharge of the resident due to her increased behaviors toward two of the residents in the facility but stated he had not completed the documentation required. Interview with Resident #1's MD on at 12:05 p.m. he stated his understanding was the resident was discharged to keep other residents safe. He stated Resident #1 had begun to target two of the residents in the facility and had been aggressive toward both those residents. He stated they had not been able to manage Resident #1 from a medical perspective because she refused to take medication for her cardiac issues as well as her chronic UTI's. He stated she would not allow lab work. He stated they had no choice but to send her out to the hospital when they were not able to deescalate her behaviors. He further stated he did not fully understand what all documentation was required when a resident was discharged from the facility, but stated he would follow up with the facility. Review of the facility's policy Transfer or Discharge Documentation, dated December 2016, reflected, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider .the following information will be documented in the medical record .If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include .the specific resident needs that cannot be met; the facility attempt to meet those needs; and the receiving facility services(s) that are available to meet those needs .A summary of the resident's overall medical, physical and mental condition .Should the resident be transferred or discharged for any of the following reason, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's Attending Physician: The transfer or discharge is necessary for the resident's welfare, and resident's needs cannot be met in the facility .The safety of individuals in the facility is endangered due to the clinical or behaviors status of the resident; or the health of individuals in the facility would otherwise be endangered .Information will be communicated to the receiving facility or provider . The basis for the transfer or discharge .The specific resident needs that cannot be met; the facility's attempt to meet those needs; and the receiving facility's services 9s) that are available to meet those needs .Contact information of the practitioner responsible for the care of the resident .Comprehensive care plan goals; and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable , to ensure a safe and effective transition of care. 455563 Page 3 of 3