**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure a resident's discharge was completely assessed, evaluated, and documented for 1 of 1 [Resident #1] residents who were involuntarily discharged from the facility. The facility initiated Resident #1's discharge based on the facility's inability to meet the resident's needs and because the behavioral status of the resident endangered the safety of other individuals in the facility. However, upon complaint investigation, it was determined by interview and record review that, while Resident #1 had challenging aggressive behavior requiring staff attention, s/he did not have needs which could not be met in that facility to allow for a planned involuntary discharge honoring the resident's rights around discharge, and there was evidence that the facility was caring for other residents with aggressive behaviors. It was also determined that the facility did not meet behavioral care needs to prevent aggressive behaviors for Resident #1. The facility based Resident #1's discharge on their status at the time of transfer, did not have the required documentation specified in the regulation, and discharged the resident on 9/8/22. Findings include: Record review reveals that Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] following a hospital stay. At the time of this readmittance, his/her diagnoses included: right sided cerebral hemisphere cerebrovascular accident (CVA) [stroke], reactive depression [adjustment disorder], spastic hemiplegia of left non dominant side [left side of body in a constant state of contraction]. Resident #1 transferred from the rehabilitation unit into a room on the long-term care unit on 5/17/2022. A geriatric psychological consult from 7/6/2022 reveals that Resident #1 has the diagnoses of major neurological disorder, vascular type with behavioral disturbance [dementia with behaviors] and antisocial personality traits. Physician progress notes from 9/7/2022 reveal that emergency medical services [EMS] and police were called into the facility on 9/7/2022 following events where Resident #1 was verbally and physically aggressive. Resident #1 was then transferred to the emergency department for evaluation. Physician progress notes from 9/8/2022 reveal that the decision to discharge was made on 9/8/2022 due to safety concerns and the facility not being able to meet the care needs of Resident #1. 1. It was established that while Resident #1's had aggressive behaviors, these behaviors had been ongoing since his/her initial admission on [DATE]. A readmission note written by Resident #1's physician on 3/28/2022 describes Resident #1 as having a problem with anxiety and depression and that s/he has had issues related to dysregulated behavior, verbal abuse and aggression directed toward staff in nursing home setting. Progress notes in Resident #1's record reveal instances at the facility on 9/24/2020, 10/27/2020, 11/16/2020, 7/1/2021, 5/13/2022, 9/4/2022, 9/6/2022, and 9/7/2022 where s/he was physically aggressive towards staff including: hitting, slapping, striking, grabbing, shoving, along with frequent verbal abuse. Instances of verbal aggression and threats towards staff are frequent in Resident #1's progress notes. Record review reveals that verbal threats towards a specific resident neighbor [Resident #2] began 7/8/2022. Per interview on 10/18/2022 at 5:00 PM, a Licensed Practical Nurse stated that when s/he worked with Resident #1 on the rehabilitation unit, Resident #1 was very aggressive and mean. Per interview on 11/1/2022 at 12:30 PM, a Social Worker confirmed that Resident #1 had a history of physically aggressive behaviors with facility staff before s/he arrived on the long-term care unit. 2. It was established that the facility is able to care for residents with aggressive behaviors. The facility assessment as of December 31, 2021, states The facility provides care and services based upon the needs of our resident population. Our facility embraces a person-centered care culture in which we provide care and services based upon our resident population, including the following: Behavior health, psycho social support, and dementia care. Per interview on 11/1/2022 at 10:55 AM, a Nurse Practitioner stated there were other residents in the facility that have aggressive behaviors, but not at the same frequency as Resident #1. Per interview on 11/1/2022 at 2:15 PM, a Licensed Nurse Aide stated that there are residents in the facility that are physically aggressive. Review of a list of residents with aggressive behaviors in the facility revealed that 16 residents with aggressive behaviors reside at the facility as of 11/1/2022. Of the 16 residents listed, at least one resident was physically aggressive with other residents and two residents were admitted after Resident #1 was discharged for aggressive behaviors. This was confirmed by the Director of Nursing on 11/1/2022 at 4:30 PM. The DON stated that Resident #1's care team had discussions prior to 9/7/2022 about at what point they would discharge Resident #1. The facility decided that Resident #1 would need to be discharged when his/her behavior impacted the safety of other residents. The DON stated that Resident #1 had never hurt another resident, but because s/he had threatened to hurt another resident on 9/6/2022, the facility was concerned there was a risk to that resident's safety. Record review shows that verbal threats to hurt another resident [Resident #2] began 7/8/2022. The DON confirmed that 9/6/2022 wasn't the first time Resident #1 made threats about hurting Resident #2. 3. It was established that Resident #1 was discharged based on his/her status at the time of transfer. Progress notes dated 9/7/2022 and 9/8/2022 by Resident #1's physician pertaining to Resident #1's transfer and discharge do not contain assessment information about Resident #1 at the time of discharge on [DATE]. Review of a hospital discharge summary [from hospital emergency room to a swing bed in the hospital] reveals the following: o Reason for admission (chief complaint): aggressive behavior, Principal/Final Diagnosis: Agitation. o Hospital Course: The staff at [the nursing facility] felt they could no longer care for [Resident #1] and [s/he] was taken to the [hospital] ED on 9/7/22 and then admitted . During [his/her] stay [s/he] was calm and redirectable. [S/he] wanted to return to [the nursing facility] where [s/he] lived for 2 years. o Clinical Issues Needing Follow-up: 1. Pertinent medication changes: n/a, 2. Recommended follow-up tests/procedures needs: work on placement, 3. Anticoagulation on discharge: No 4: Changes to goals care at time of discharge (if applicable): n/a o Assessment: [Resident #1 is] here for placement as [s/he] is displaying behaviors at [the nursing facility]. [S/he] will remain at [the hospital] awaiting placement. Per interview with members of Resident #1's hospital care team on 11/1/2022 at 4:01 PM, a Registered Nurse from the admitting hospital stated that Resident #1 was calm for the first few days s/he arrived at the hospital. The Director of Case Management stated that there had been no discussions with the nursing facility about what it would take for Resident #1 to go back to the nursing facility, rather the nursing facility and hospital have been discussing how best to support him/her in the hospital. Per interview on 11/1/2022 at 4:30 PM, the Director of Nursing stated that there was no expectation for Resident #1 to return to the facility after s/he left on 9/7/2022. The Director of Nursing and Chief Nursing Officer both confirmed that discharge from the facility was based on his/her behavior when s/he was transferred to the hospital. 4. It was established that Resident #1's care plan was not revised to include interventions based on new behaviors or new diagnoses to prevent aggressive behaviors. Progress notes reveal Resident #1 made a complaint to social services about the nightly noise of a resident neighbor [Resident #2] on 7/7/2022. On 7/8/2022, Resident #1 complained to social services again and expressed a desire to hurt Resident #2. Progress notes continue to reveal that Resident #1 was triggered by Resident #2 and threats by Resident #1 were only made about Resident #2. A note from 9/6/22, the last reported incident of Resident #1 making threats about hurting a resident stated that Resident #1 started heading back to [his/her] room when [s/he] made comments at staff and a patient who was talking out loud [Resident #2]. [Resident #1] made the comment about [Resident #2] saying '[s/he] was going to take a brick and knock [him/her] in the head with it.' There was no documentation in record review from 7/1/2022 through 9/7/2022 that Resident #1 made threats about hurting any resident other than Resident #2 and staff did not reveal threats to any other residents in any of the interviews conducted. Per interview on 11/1/2022 at 1:04 PM, a Charge Nurse confirmed that the Resident #2's yelling was a trigger for Resident #1. S/he stated that the facility put interventions into Resident #2's care plan to address the noise and confirmed that no interventions were added into Resident #1's care plan to address this. A geriatric psychiatry evaluation and request for behavioral management was made by Resident #1's physician, conducted on 7/6/2022 revealed the following diagnosis: Major Neurocognitive disorder, vascular type with behavioral disturbances, Alcohol use disorder- in remission, antisocial personality traits. The following recommendations were made to Resident #1's plan of care: Implement DICE approach [method used by dementia behavior experts] to address problematic behaviors in the long-term care setting. We recommend that you revisit behavioral plans frequently to evaluate for efficacy, and staff psychoeducation around patient's diagnosis. Specifically that the difficult behaviors and statements resultant from his underlying personality structure have been exacerbated by disinhibition resultant from his CVA. The report from this visit was signed by the Psychiatry Resident on 7/7/2022 and signed by the attending provider on 7/13/22. Notes from this visit are automatically in the resident's medical record. Nursing notes state that Resident #1's care plan was reviewed on 7/17/2022. Care plan has been reviewed by all departments and has been updated as needed as of this date. Complete Care Plan is reviewed and continued. Review of a Care Plan Event Log shows that Resident #1's care plan was revised on 7/19/22 but the facility was unable to produce the revisions that were made. The Care Plan Event Log also revealed that Resident #1's care plan had not been updated since 8/2/2022. This was confirmed by the Administrator on 10/20/2022 at 2:33 PM. Record review reveals that it wasn't until an 8/29/2022 multidisciplinary staff meeting, held to formulate a patient behavior plan, that the recommendation to implement the DICE method and develop a plan for staff psychoeducation around Resident #1's behaviors was discussed as part of Resident #1's behavior plan. Review of Resident #1's most recent care plan does not reveal interventions for: dementia, the DICE approach, preventing Resident #1 from being triggered by Resident #2, or verbal threats to other residents. 5. Review of a progress note written by Resident #1's physician on 9/8/2022 regarding his/her discharge indicate the basis for discharge is based on safety concerns for staff and that the facility does not feel that they can meet [his/her] care needs in this setting. This progress note does not document the following required information in the resident's medical record: the specific resident needs the facility could not met and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. 6. Resident #1 suffered harm by not being able to return to the nursing facility. Per observation at the hospital on [DATE] at 3:45 PM, Resident #1 was in bed. S/he was agitated and made comments about wanting to die and wanting to leave and go home. Per interview at the hospital on [DATE] at approximately 4:00 PM, a Registered Nurse stated that Resident #1 does not have a chance to hurt other residents at the hospital because s/he is mostly in his/her room. Staff do try to bring him/her out for a walk once a day. Per interview with Resident #1's representative at 4:01 PM on 11/2/2022, s/he stated that s/he believes Resident #1 is getting less care at the hospital than s/he was at the nursing home. At the hospital Resident #1 stays in his/her room most of the time and does not have access to activities or other residents. The representative stated that the nursing facility was Resident #1's home for the past 2 year and s/he should be able to go back to his/her home. A 9/9/2022 hospital physician note serving as both a discharge summary from the emergency room and admission summary for hospital swing bed status reveals that Resident #1 wanted to return to [nursing facility] where [s/he] lived for 2 years. Under Assessment it states that s/he will remain at the hospital awaiting placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish a protocol on permitting resident to return to the facility after they are hospitalized or placed on therapeutic leave and failed to allow one of one sampled residents [Resident #1] to return to the facility after a behavioral episode. Findings include: Record review reveals that Resident #1 was transferred to an acute facility on 9/7/2022 for an evaluation due to physical aggressive behaviors. A progress note written by Resident #1's physician on 9/8/2022 states the facility initiated discharge, discussed on 9/8/2022, is due to safety concerns for staff and vulnerable residents and that the facility does not feel they can meet his/her care needs. The notice of discharge reveal that Resident #1 was discharged from the facility on 9/7/2022. An appeal for discharge was sent to the Administrator on 9/16/2022 by Resident #1's representative. As of 11/1/2022 Resident #1 was still residing at the hospital awaiting placement to a nursing facility. 1. Record review and interview reveal that Resident #1 was discharged based on his/her status at the time of transfer. Progress notes dated 9/7/2022 and 9/8/2022 by Resident #1's physician pertaining to Resident #1's transfer and discharge do not contain assessment information about Resident #1 at the time of discharge on [DATE]. Review of a hospital discharge summary [from hospital emergency room to a swing bed in the hospital] reveals the following: -Reason for admission (chief complaint): aggressive behavior, Principal/Final Diagnosis: Agitation. -Hospital Course: The staff at [the nursing facility] felt they could no longer care for [Resident #1] and [s/he] was taken to the [hospital] ED on 9/7/22 and then admitted . During [his/her] stay [s/he] was calm and redirectable. [S/he] wanted to return to [the nursing facility] where [s/he] lived for 2 years. -Clinical Issues Needing Follow-up: 1. Pertinent medication changes: n/a, 2. Recommended follow-up tests/procedures needs: work on placement, 3. Anticoagulation on discharge: No 4: Changes to goals care at time of discharge (if applicable): n/a -Assessment: [Resident #1 is] here for placement as s/he is displaying behaviors at [the nursing facility]. [S/he] will remain at [the hospital] awaiting placement. Per interview with members of Resident #1's hospital care team on 11/1/2022 at 4:01 PM, a Registered Nurse from the admitting hospital stated that Resident #1 was calm for the first few days s/he arrived at the hospital. The Director of Case Management stated that there had been no discussions with the nursing facility about what it would take for Resident #1 to go back to the nursing facility, rather the nursing facility and hospital have been discussing how best to support him/her in the hospital. Per interview on 11/1/2022 at 4:30 PM, the Director of Nursing stated that there was no expectation for him/her to return to the facility after s/he left on 9/7/2022. The Director of Nursing and Chief Nursing Office both confirmed that discharge from the facility was based on Resident #1's behavior when s/he was transferred to the hospital. Per interview on 11/1/2022 at 2:59 PM, Resident #1's representative stated that s/he never heard back as to whether Resident #1 could return back to the facility. At 4:01 PM on 11/2/2022, s/he stated that s/he believes Resident #1 is getting less care at the hospital than s/he was at the nursing home. At the hospital Resident #1 stays in his/her room most of the time and does not have access to activities or other residents. The representative stated that the nursing facility was Resident #1's home for the past 2 year and s/he should be able to go back to his/her home. 2. Per interview on 11/1/2022 at 2:45 PM the Director of Nursing confirmed that the facility did not have a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop individualized interventions related to a resident's diagnosed conditions, recommendations from a geriatric psychiatric consultation, and identified triggers in order to attain or maintain their highest practicable physical, mental and psychosocial well being for 1 of 3 residents [Resident #1]. Findings include: Record review reveals that Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] following a hospital stay. At the time of this readmittance his/her diagnoses included: right sided cerebral hemisphere cerebrovascular accident (CVA) [stroke], reactive depression, spastic hemiplegia of left non dominant side [left side of body in a constant state of contraction]. A readmission note written by Resident #1's physician describes Resident #1 as having a problem with anxiety and depression and that s/he has had issues related to dysregulated behavior, verbal abuse and aggression directed toward staff in nursing home setting. Progress notes reveal instances on 9/24/2020, 10/27/2020, 11/16/2020, 7/1/2021, 5/13/2022, 9/4/2022, 9/6/2022, and 9/7/2022 where s/he was physically aggressive towards staff including hitting, slapping, striking, grabbing, shoving, along with frequent verbal abuse. Instances of verbal aggression and threats towards staff are frequent in Resident #1's progress notes. Record review reveals that verbal threats towards a specific resident neighbor began in early July 2022. A geriatric psychiatry evaluation and request for behavioral management was made by Resident #1's physician, conducted on 7/6/2022 revealed the following diagnosis: Major Neurocognitive disorder, vascular type with behavioral disturbances, Alcohol use disorder- in remission, antisocial personality traits. The following recommendations were made to Resident #1's plan of care: Implement DICE approach [method used by dementia behavior experts] to address problematic behaviors in the long-term care setting. We recommend that you revisit behavioral plans frequently to evaluate for efficacy, and staff psychoeducation around patient's diagnosis. Specifically that the difficult behaviors and statements resultant from his underlying personality structure have been exacerbated by disinhibition resultant from his CVA. The report from this visit was signed by the Psychiatry Resident on 7/7/2022 and signed by the Attending Provider on 7/13/22. Notes from this visit are automatically in the resident's medical record. Nursing notes state that Resident #1's care plan was reviewed on 7/17/2022. Care plan has been reviewed by all departments and has been updated as needed as of this date. Complete Care Plan is reviewed and continued. Review of a Care Plan Event Log shows that Resident #1's care plan was revised on 7/19/22 but the facility was unable to produce the revisions that were made. The Care Plan Event Log also revealed that Resident #1's care plan had not been updated since 8/2/2022. This was confirmed by the Administrator on 10/20/2022 at 2:33 PM. Review of Resident #1's most recent care plan does not reveal interventions for: dementia, the DICE approach, preventing Resident #1 from being triggered by the resident neighbor who yells, or verbal threats to other residents. Record review reveals that it wasn't until an 8/29/2022 multidisciplinary staff meeting, held to formulate a patient behavior plan, that the recommendation to implement the DICE method and develop a plan for staff psychoeducation around Resident #1's behaviors was discussed as part of Resident #1's behavior plan. Progress notes reveal Resident #1 made a complaint to social services about the nightly noise of a resident neighbor [Resident #2] on 7/7/2022. On 7/8/2022, Resident #1 complained to social services again and expressed a desire to hurt Resident #2. Progress notes continue to reveal that Resident #1 transfer reveal that s/he was triggered by this resident neighbor and threats by Resident #1 were only made about Resident #2. Per interview on 11/1/2022 at 11:55 AM, when asked why the diagnoses and behavioral interventions were not incorporated into Resident #1's care plan, a Nurse Practitioner stated that the team was getting the conversation started about implementing the psychiatric consult plan of care but that it likely fell through the cracks. S/he stated that it would ultimately be the Physicians and Director of Nursing's responsibility to incorporate diagnoses and recommendations into the resident's plan of care. Per interview on 11/1/2022 at 1:04 PM the Charge Nurse confirmed that Resident #1's care plan did not address the resident's diagnosis of dementia and that it did not include interventions that were recommended in geriatric psychiatric evaluation. S/he also stated that interventions were not put into Resident #1's care plan to address how the resident neighbor triggers aggressive behaviors for Resident #1. This was later confirmed on 11/1/2022 at 4:30 PM by the Director of Nursing. Per interview on 11/1/2022 at 6:15 PM, the Medical Director stated that the team did have meetings about the geriatric psychiatric consult, and it would be the DON and nurses to incorporate the information into his/her chart and care plan. S/he confirmed that the information from this consult is part of Resident #1's medical record, including the new diagnoses. Per interview on 11/2/2022 at 4:01 PM, Resident #1's representative stated that s/he did not believe that the facility exhausted all options for interventions. Resident #1 did not get care based on his/her diagnosis of dementia and the facility did not implement the DICE approach. S/he stated that they did not update any interventions except medications changes since Resident #1's geriatric psychiatric consultation and that s/he was told by the facility that he did not have dementia. Record [NAME] reveals that Resident #1 was transferred to an acute facility on 9/7/2022 with physical aggressive behaviors for an evaluation. A progress note written by Resident #1's physician on 9/8/2022 states the facility initiated discharge, discussed on 9/8/2022, is due to safety concerns for staff and vulnerable residents and that the facility does not feel they can meet his/her care needs. The notice of discharge reveal that Resident #1 was discharged from the facility on 9/7/2022. An appeal for discharge was sent to the Administrator on 9/16/2022 by Resident #1's representative. As of 11/1/2022 Resident #1 was still residing at the hospital awaiting placement to a nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide sufficient staff who have the training to address behavioral health care needs for 1 of 2 residents [Resident #1] Findings include: Record review reveals that Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] following a hospital stay. At the time of this readmittance his/her diagnoses included: right sided cerebral hemisphere cerebrovascular accident (CVA) [stroke], reactive depression, spastic hemiplegia of left non dominant side [left side of body in a constant state of contraction]. A readmission note written by Resident #1's physician describes Resident #1 as having a problem with anxiety and depression and that s/he has had issues related to dysregulated behavior, verbal abuse and aggression directed toward staff in nursing home setting. A geriatric psychiatry evaluation and request for behavioral management was made by Resident #1's physician, conducted on 7/6/2022 revealed the following diagnosis: Major Neurocognitive disorder, vascular type with behavioral disturbances, Alcohol use disorder- in remission, antisocial personality traits. The following recommendations were made to Resident #1's plan of care: Implement DICE approach [method used by dementia behavior experts] to address problematic behaviors in the long-term care setting. We recommend that you revisit behavioral plans frequently to evaluate for efficacy, and staff psychoeducation around patient's diagnosis. Specifically that the difficult behaviors and statements resultant from [his/her] underlying personality structure have been exacerbated by disinhibition resultant from [his/her] CVA. The facility assessment as of December 31, 2021, states The facility provides care and services based upon the needs of our resident population. Our facility embraces a person-centered care culture in which we provide care and services based upon our resident population, including the following: Behavior health, psycho social support, and dementia care. The Staff Education, Training, and Competencies section states additional competencies are determined according to the job role, job specific knowledge, skills and abilities and those needed to care for a specific resident population. Per interview on 10/18/22 at 12:45 PM, a Registered Nurse stated that travel nursing staff do not get adequate training to work with residents with dementia. Per interview on 10/19/22 at approximately 11:25 AM, the Director of Nursing stated that staff were given a handout titled [Resident #1] Tip Sheet as education around Resident #1. Review of this document does not reveal any staff psychoeducation around Resident #1's diagnosis. Per interview on 10/19/22 at approximately 2:00 PM, a Licensed Nursing Assistant stated s/he did not receive special training regarding Resident #1. Per interview on 11/1/2022 at 11:24 AM, a Licensed Nurse Aide (LNA) stated that the behavior training s/he received from the facility was computer-based training and s/he only got one day of training on the floor and the was on his/her own. S/he confirmed that she did not get any training about Resident #1 and that it would have been valuable to get more training about Resident #1 specifically. On 11/1/2022 at 11:55, the Director of Nursing confirmed that there was no staff psychoeducation around patient's diagnoses. On 11/1/2022 at 1:04 PM, a Charge Nurse stated that travelers have less training than permanent staff, as they do not have a full-blown training. On 11/1/2022 at 2:15 PM, an LNA stated that they did not have any specific training about Resident #1 or his/her diagnoses. Record [NAME] reveals that Resident #1 was transferred to an acute facility on 9/7/2022 with physical aggressive behaviors for an evaluation. A progress note written by Resident #1's physician on 9/8/2022 states the facility initiated discharge, discussed on 9/8/2022, is due to safety concerns for staff and vulnerable residents and that the facility does not feel they can meet his/her care needs. The notice of discharge reveal that Resident #1 was discharged from the facility on 9/7/2022. An appeal for discharge was sent to the Administrator on 9/16/2022 by Resident #1's representative. As of 11/1/2022 Resident #1 was still residing at the hospital awaiting placement to a nursing facility.