Health inspection·December 10, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #1) Residents Affected - Few The facility failed to make arrangements for a safe discharge for Resident #1. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted [DATE] with diagnoses of unspecified systolic congestive heart failure (the left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation), essential primary hypertension (abnormally high blood pressure that not caused by a medical condition), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. Resident #1 required set up or clean up assistance in the areas of eating, oral hygiene, upper body dressing, and personal hygiene, Resident #1 required partial/moderate assistance in the areas of lower body dressing and shower/bathe self. Resident #1 required substantial/maximal assistance in the areas of toileting hygiene and putting on/taking off footwear. Review of Resident #1's care plan dated 12/10/24, revealed Resident #1 was care planned for the following: Resident #1 wished to be discharged to an apartment. Review of Resident #1's 30-day discharge letter dated 10/09/24, revealed Resident #1 was given the 30-day discharge letter on the same date (10/09/24) he was discharged to the psych facility. Review of Resident #1's Interdisciplinary Discharge Summary date 10/11/24, revealed Resident #1 was sent to the psychiatric facility for evaluation and treatment. During an interview on 12/10/24 at 1:20 p.m., the SW stated that the resident was having several behaviors such as putting the remote to the tv in his pants, threatening other residents, and forced his roommate to watch gay porn. The SW stated Resident #1's former roommate was discharged from the facility as well but provided the investigator his face sheet with a phone number attached. The SW (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675065 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cass Valley Healthcare Center 103 Teakwood St Centerville, TX 75833 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)