Health inspection·February 9, 2025

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 permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 4 residents (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted to the facility, after being sent to the hospital for behaviors. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. Findings included: A record review of Resident #1's face sheet dated 01/21/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis was unspecified dementia(memory loss), blindness right eye(unable to see), hearing loss(unable to hear), and essential primary hypertension(high blood pressure). A record review of Resident #1's Initial MDS assessment, dated 01/20/2025, reflected the resident had a BIMS score of 0, which indicated severe cognitive impairment. A record review of Resident #1's care plan, dated 02/05/2025, reflected focus of discharge from the facility is not feasible as evidence by dementia. The goal reflected Resident #1 would be provided an opportunity to receive information on returning to the community. The intervention for Resident # 1 was to respect resident's rights to view nursing facility as his home Review of Resident #1's 30-day discharge letter dated 01/21/2025, revealed Resident #1 was given the 30-day discharge letter on the same date (01/21/2025) he was discharged to the hospital. The discharge letter was delivered to hospital ER on [DATE] with Resident #1. Review of Resident #1's Discharge Planning and Summary date 01/21/2025, revealed Resident #1 was sent to the hospital for behaviors. Attempted an interview on 02/09/2025 at 12:10 p.m. left message for the local ombudsman to return call. Page 1 of 2 455601 455601 02/09/2025 Alvarado Meadows Nursing & Rehabilitation 101 N Parkway Alvarado, TX 76009

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/09/2025 at 3:00 p.m., the RP stated he received a text message from someone at the facility on 01/21/2025 late that evening ,time not recalled, that Resident # 1 could not come back to the facility. The RP stated he was not notified by the facility that a discharge had been in place. The RP stated Resident # 1 was not able to make any decision's and he was not able to participate in finding Resident # 1 placement at another facility. The RP stated no discharge paperwork was given to him and he had not signed anything for the Resident to be placed at another facility. The RP stated Resident # 1 was sent to the hospital for non-emergency and was not allowed to return to the facility. The RP stated Resident # 1 was discharged from the hospital to another nursing facility. During an interview on 02/09/2025 at 3:30 p.m., the SW stated she was not aware Resident # 1 was discharged from the facility to the hospital on [DATE]. The SW stated she did not find out about the discharge until when she returned to the facility on [DATE]. The SW stated she had not been involved with an immediate discharge with Resident #1. During an interview on 02/09/2025 at 3:45 p.m., the BOM stated she did not partake in the immediate discharge of Resident # 1. The BOM stated she just discharged Resident #1 out of the system. The BOM stated that she did not partake in the immediate discharges. The BOM stated the ADM and the DON handled the immediate discharge for Resident #1. During an interview on 02/09/2025 at 4:16 p.m., the DON stated she had just started the facility on 02/07/2025 and was not in the facility when Resident # 1 was immediate discharged from the facility. During an interview on 02/09/2025 at 4:20 p.m., the ADM stated the immediate discharge was given on 01/21/2025 the same day he was sent to the hospital for behaviors. The ADM stated no 30-day notice was given an immediate discharge was initiated for the safety and well being of all residents. The ADM stated he had been working as an ADM for two weeks when Resident # 1 as immediately discharged . The ADM stated corporate was in the building and it was thought you could issue an immediate discharge if there was a safety concern for all the other residents. The ADM stated Resident # 1 was sent out to the hospital for behaviors and not for a medical emergency. The ADM stated when a 30 day notice was not provided the family would not be able to participate in the decision of resident's stay. Review of long-term care regulation provider letter dated 12/29/2022 reflected If a NF initiates a resident discharge, the facility must provide written notification of the discharge-in a language and manner the resident can understand-to the resident, the resident representative (if applicable), and a representative of the Long-Term Care Ombudsman Program, at least 30 days before the intended discharge date . Review of nursing policy and procedure manual titled facility-initiated discharge date d 12/2017 revised 04/10/2024 reflected The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility. In the following circumstances this facility may initiate transfers and discharges. The safety of individuals in facility is endangered due to clinical behavioral status of the resident. 455601 Page 2 of 2