Health inspection·June 22, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for two (Residents #1 and #2) of six residents reviewed for abuse. The facility failed to prevent Resident #1 and #2 from having unwanted sexual exposure and contact by Resident #3. This failure placed residents at risk of being abused by a fellow resident. Findings included: Review of Resident #1's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged home on [DATE]. Resident #1 had diagnoses including heart failure, dementia and stroke causing difficulty speaking. Review of Resident #1's discharge MDS, dated [DATE], her BIMS score was not calculated due to her medical conditions. Her Functional Status indicated she required limited assistance with all her ADLs. Review of Resident #1's care plan, dated 12/08/22, revealed she had impaired cognitive function related to her dementia and a communication deficit related to difficulty speaking. Review of Resident #2's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included emphysema, dementia, communication deficit, and anxiety. Review of Resident #2's annual MDS, dated [DATE], her BIMS score was calculated to be 3 indicating severe cognitive impairment. Her Functional Status indicated she required limited assistance with most of her ADLs except locomotion which required supervision only. Review of Resident #2's care plan, dated 04/25/23, revealed she had impaired cognitive function and communication deficits related to dementia, and wandering habits related to dementia. Review of Resident #3's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included gangrene infection to left toes, anemia, morbid obesity, and kidney disease. On 02/04/21, a diagnosis of sexual dysfunction was added. Page 1 of 3 675963 675963 06/22/2023 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0600 Review of Resident #3's quarterly MDS, dated [DATE] his BIMS score was calculated to be 15 indicating he was cognitively intact. His Functional Status indicated he was independent in most of his ADLs. Level of Harm - Actual harm Residents Affected - Few Review of Resident #3's discharge MDS, dated [DATE], his BIMS score was calculated at 14 indicating he was still cognitively intact. His Behavior did not indicate he exhibited behaviors directed at others. Review of Resident #3's care plan, dated 06/16/23, revealed he exhibited sexually inappropriate behavior by exposing himself to staff or others who enter his room beginning on 03/03/21. Resident #3 preferred to not wear pants, and draped his lap with blankets, towels or pants. Review of Resident #3's physician orders revealed Resident #3 was started on testosterone replacement therapy at 100 mg weekly on 01/14/21, and it was discontinued on 10/07/21. Review of Resident #3's physician note dated 03/25/21 indicated he was aware of resident #3's hypersexual behaviors and had spoken with him about the behaviors. Review of Resident #3's psychiatrist visit notes dated 11/15/21 revealed he had been taken off testosterone because of inappropriate behavior of exposing himself to staff and physician and standing in his doorway with no clothes on. Review of Resident #3's progress notes revealed the Social Worker documented on 10/07/21: This SW spoke to res about maintaining privacy during masturbation. Reminded him that it is his right but that he must maintain privacy and not allow others into his room during these activities. Res verbalized understanding. Interview on 06/22/23 at 10:00 AM Resident #2 had difficulty speaking. When asked by the surveyor about anyone being inappropriate with her, tears began to form and she stated, I can't tell you. The resident would not make eye contact after that. Interview on 06/22/23 at 10:38 AM the family member of Resident #1 stated she was visiting the resident in the lobby of the facility when the resident complained of being cold. The family member went to the resident's room to retrieve a jacket. When she returned to the lobby, Resident #3 was sitting in his wheelchair directly in front of Resident #1 with no clothes on below the waist leaving his genitals exposed to Resident #1. The family member yelled at Resident #3 and someone from an office came out and took him away. The family member stated Resident #1 was upset and stated, I didn't like that. Interview on 06/22/23 at 12:50 PM the ADON stated on 06/16/23 a CNA was looking for Resident #2, who was known to wander the facility in her wheelchair. The CNA found Resident #2 in Resident #3's room, with her hand on Resident #3's penis and it was being held in place by Resident #3. The CNA called for help and the two residents were separated. Resident #3 was placed on 1:1 monitoring. The ADON stated Resident #3 had been just like any other resident when he was first admitted , but then a couple of years into his stay Resident #3 began to watch pornography on his phone and his TV. Resident #3 began to masturbate after he began watching pornography, and he was educated on keeping his door shut and not doing it when staff were present. The ADON stated staff knew to knock on his door before entering to make sure he was decent before entering his room. Within a few months, Resident #3's behaviors began to expand to exposing himself to staff in his room, and making inappropriate 675963 Page 2 of 3 675963 06/22/2023 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0600 Level of Harm - Actual harm Residents Affected - Few statements to staff about sexual activities he would like to try. The ADON stated in the last two months Resident #3 began to make more explicit comments and requests to staff. The ADON stated Resident #3 had to be counseled after every event reported by staff, which happened at least once a week. The ADON stated that as far as she knew, Resident #3 focused on staff and never involved the residents in his behaviors. The ADON stated the only interventions to curb Resident #3's behaviors, that she knew of, were stopping his testosterone therapy, seeing the psychiatrist, and educating him on his behaviors. Interview on 06/22/23 at 2:00 PM the DON stated Resident #3's behaviors had been restricted to staff in his room until the two episodes when he involved Residents #1 and #2. He stated Resident #3 stayed in his room most of the time, keeping to himself and occasionally going out to the patio. When Resident #3 was out of his room he kept his lap covered with a towel, blanket or a pair of pants. The DON stated whenever there was an incident with staff, Resident #3 would be educated about his behaviors. The DON stated after the incident with Resident #1, that occurred around 4:00 PM on 05/25/23 , Resident #3 was taken back to his room and the DON educated him about his behaviors again. After the incident with Resident #2 on 06/16/23, Resident #3 was placed on 1:1 monitoring in his room, the police were called, and Resident #3 was transferred out of the facility to an all-male facility within about 3 hours. Interview on 06/22/23 at 2:10 PM, LVN A stated she was present for the incident on 05/25/23 between Residents #1 and #3. She stated Resident #3 had been educated about being clothed, or having his private area covered, when he left his room. LVN A stated shortly after that the resident was again back in the hallway, naked and yelling for his medications and had to be educated again. LVN A stated the resident rarely came out of his room, he would come out and yell for medications but could be easily redirected back to his room. She stated she had never seen, or heard about, Resident #3 involving other residents in his behavior. Interview on 06/22/23 at 2:40 PM, CNA B stated Resident #3 stayed in his room most of the time, and he did not interact with the other residents when he came out of his room. When he was out of his room he would cover his lap with something, and if he didn't he would be reminded to do so. She stated he had not heard of Resident #3 being inappropriate with other residents, just with staff. CNA B stated Resident #3 would tell them it was just the way he was, and they would have to deal with it. Review of Resident #3's nursing progress note from 05/25/23 at 5:57 PM written by LVN A revealed: I was called by med aide in the middle of hallway on 500 hall and saw resident completely naked, sitting and propelling on his wc and asking for his pain pills. Res. was covered, educated and redirected to his room. Notified supervisor, DON and SW. Interview on 06/22/23 at 4:00 PM, the Administrator stated as far as she was aware Resident #3 had never involved other residents in his behaviors until the two recent incidents. The Administrator stated Resident #3 had not been closely monitored since his behaviors began in 2021, because his behaviors only affected staff. The Administrator stated that failing to monitor or transfer Resident #3 when his behaviors began, led to him involving two resident in his behaviors. Review of the facility's policy Abuse/Neglect revised on 03/29/18, defined sexual abuse as non-consensual contact of any type with a resident. The policy reflected, The facility will provide the resident, families, and staff an environment free from abuse and neglect. 675963 Page 3 of 3