Health inspection·April 2, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the resident's Ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 4 residents (Resident #1) reviewed for Discharge Rights. The facility failed to notify Resident #1's Ombudsman in writing of the transfer/discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female with an initial admission date of 08/06/2024. Resident #1 was discharged to a behavioral hospital on [DATE] with a warrant for emergency detention. Resident #1's diagnoses was Unspecified Dementia, (mental decline without a specific underlying diagnosis) unspecified severity, with psychosis disturbance (group of mental health disturbances characterized by a loss of touch with reality, leading to abnormal thoughts, perceptions and behaviors), Major Depressive Disorder (serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and Generalized Anxiety Disorder (severe ongoing anxiety that interferes with daily activities). Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 5 indicating severe cognitive impairment. Review of an Application for Emergency Apprehension and Detention dated 01/25/2025 and signed by the ADM reflected Resident #1 has been having very poor and combative behavior. She has been disturbing the peace of the community in the nursing facility. Review of a Notice of Discharge or Transfer dated 02/24/2025 for Resident #1 and e-mailed to her Guardian on 02/24/2025 reflected she was being discharged from the facility. The document did not include the correct name of the Ombudsman and no address was provided. Review of the Warrant for Emergency Detention for Resident #1 dated 3/25/2025 reflected there was reasonable cause to believe that the person evidences mental illness; that the person evidences substantial risk of serious harm to the person or others; that the risk of harm is imminent unless the Page 1 of 2 675132 675132 04/02/2025 Bremond Nursing and Rehabilitation Center 211 N Main Bremond, TX 76629

F 0623 Level of Harm - Minimal harm or potential for actual harm person is immediately restrained; and that necessary restraint cannot be accomplished without emergency detention. In a telephone interview on 04/01/2025 at 10:53 AM, the Ombudsman stated she did not receive a copy of the discharge notification for Resident #1 of the facility's intent to discharge. Residents Affected - Few In an interview on 04/02/2025 at 11:53 AM, the ADM stated I didn't send a written notice to the Ombudsman of the discharge for Resident #1. I sent one to the guardian. I should have sent a written notice to the Ombudsman, but I tried to reach her by phone twice. In an interview on 04/02/2025 at 12:37 PM, the DON stated the facility follows CMS policy, and it was a learning process. She provided a copy of the admission, transfer and discharge rights that she said the facility was supposed to follow. She stated she had started a training for employees. Review of a document dated 3/31/2025 and provided by the DON on 04/02/2025 revealed Title 42-Public Health, Chapter IV- Centers for Medicare and Medicaid Services, Department of Health and Human Services, Subchapter G- Standards and Certifications, part 483- requirements for States and Long-Term care Facilities. Transfer and Discharge- Facility requirements- (3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must (1) Notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. No documentation was provided by the ADM at the time of exit from the facility of a written notice of discharge to Resident #1's Ombudsman. 675132 Page 2 of 2