Health inspection·June 26, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the discharge of Resident #1 was documented in the EMR for one resident (#1) of four residents reviewed for discharge. The facility failed to provide Resident #1 with a 30-day discharge notice when he was sent to the hospital for a change in condition and the facility refused to take him back. Documentation of discharge was not present in Resident #1's EMR to include physician's orders or a discharge summary. This failure could affect residents who go to the hospital for a change in condition and result in an unsafe discharge. The findings included: Record review of Resident #1's electronic face sheet dated 06/25/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: Pressure ulcer (a localized injury to the skin and underlying tissue) of other cite, unstageable (depth of wound could not be determined), neurogenic bladder (condition where nerve damage disrupts the normal function of the bladder), neurogenic bowel (condition where nerve damage disrupts the normal function of the bowel), constipation, a (infrequent bowel movements or difficulty passing stools) and quadriplegia (paralysis and/or weakness affecting all four limbs). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he scored a fifteen out of fifteen on his BIMS which indicated he was cognitively intact. He could understand and be understood. He had a suprapubic urinary catheter (tube inserted through a small incision in the abdomen, just above the pubic bone to drain urine from the bladder) and was always incontinent of bowel. He had a Stage 4 pressure ulcer to his sacrum (wound is deep and severe, extending beyond skin and fat layers to expose muscle, tendon, or bone). Review of Resident #1's care planning notes dated 04/29/2025 reflected he had a care plan conference which addressed he refused and was non-compliant with following MD orders/recommendations i.e.: repositioning, and lying down to relieve pressure from wounds, resident likes to sit up in his wheelchair for long periods of time. Record review of Resident #1's comprehensive care plan reflected start date, 11/06/24, revised 3/24/25, category Behaviors. Non-compliant with smoking policy and procedures. Record review of Resident #1's comprehensive care plan revised date of 03/24/25 reflected discharge Page 1 of 3 455804 455804 06/26/2025 Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few planning: Return to Community Referral desires to transition to community or another nursing facility. Long Term Goal Target Date: 06/11/2025, Approach, assist with discharge planning needs to include coordination of HH, PCP follow up and DME needs. Record review of Resident #1's change in condition Observation Detail List Report dated 06/06/2025 reflected Resident #1 was discharged , Resident requesting to go to ER due to him not feeling well, per family wanting him to go and get checked out, family at bedside, vitals with normal range. Record review of Resident #1's EMR on 06/25/2025 reflected there were no discharge orders or discharge summary for 06/06/2025. The facility provided the surveyor with a discharge order and summary dated 06/26/2025. Record review of Resident #1's hospital review of his encounter in the ER dated 06/06/2025 reflected Social History: Reports that he has never smoked. He has never used smokeless tobacco. He reports that he does not currently use alcohol. He reports current drug use. Frequency: twenty times per week. Drug: Marijuana. During an interview on 06/23/2025 at 4:00 pm with Resident #1 via telephone, he stated he was in the hospital and made a statement about using marijuana, but it was not true, and the facility refused to take him back which impacted his ability to go across the street and pick up his son from school, and there was not many facilities that would do rectal stimulation, which is a part of care he needed. During an interview on 06/25/2025 at 08:28 am with Regional Consultant RN A, she stated Resident #1 was non-compliant with his wound care and does not off load to get pressure off from his bottom and he missed appointments with the wound care doctor. She stated there was suspicion of drug use, and he would leave the facility and return at 3 am. She stated there was concern Resident #1 was selling drugs outside the facility but there was no evidence. She stated there was drug paraphernalia found in his room. She stated, the Administrator, DON and SW decided it was a big liability for the facility, and when his paperwork from the hospital showed he smoked marijuana daily the decision was made to take a citation instead of having him come back. Resident #1 was considered a risk and an endangerment to others. She stated Resident #1 was on psychoactive medications. During an interview on 06/25/2025 at 2:26 pm with Dr. B, who was Resident #1's physician and the Medical Director for the facility stated Resident #1's drug use was highly suspicious, and he would have conversations with the resident about his narcotics. He supported the facility's decision not to readmit Resident #1. He stated he was not aware at the time Resident #1 was discharged , but knew he was sent out for a change in condition. During an interview on 06/26/2025 at 10:44 am with the SW, he stated he had worked at the facility for almost one month and did not know Resident #1 well but supported the decision of not taking the resident back based on his behaviors and suspected drug use. During an interview on 06/26/2025 at 1:16 pm with the DON, she stated the facility received information from the hospital that Resident #1 smoked marijuana about twenty times a week. She stated he was young, and it would be difficult to ensure his safety since he was on narcotics for pain and used an electric wheelchair. She stated she was a new DON and did not realize a discharge order nor summary was done for Resident #1. She stated after the decision not to readmit Resident #1; it was not well communicated. She stated a smooth discharge process for a resident was essential to provide 455804 Page 2 of 3 455804 06/26/2025 Northgate Health and Rehabilitation Center 5757 N Knoll San Antonio, TX 78240

F 0628 safety and necessary care. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/26/2025 at 2:00 pm with the Administrator, she stated when the hospital reported Resident #1 was smoking marijuana, she and the DON decided it was a safety risk to other residents. She stated she was aware he refused much of his care and was not in the building. Residents Affected - Few Record review of the facility Nursing Policy and Procedure, titled Discharge-Transfer of the Resident dated 10-2020 reflected It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software., the attending physician is required to write a discharge order, discharge summary completed by DON/designee. 455804 Page 3 of 3