Health inspection·November 1, 2023

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 interview and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 7/14/23. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's electronic face sheet, dated 10/31/23 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include fracture of unspecified part of neck, Depressive Disorder, and type 2 diabetes mellitus. Review of Resident #1's progress notes dated 7/14/23 indicated Resident #1 discharged home with her prescriptions and personal items. Resident #1's family member was at the facility to assist with the discharge and transport he resident home. The resident was in stable condition at time of discharge. Electronic communication via email dated 11/1/23 Ombudsman wrote: The Ombudsman Program has not received any 30-day discharge notices since 3.21.2022 and has not received transfer/discharge reports since 6.7.2023, from the facility. During an interview on 11/1/23 at 3:15 PM the ADMIN stated the social worker should be the one that handles all discharges and documentation even with the Ombudsman. She stated a spreadsheet of all residents who were transferred out of the facility should be kept and emailed to the Ombudsman monthly. During an interview on 10/26/2022 at 2:25 the SW stated that for long term care discharges there was 30-day notice but if they were only in the facility for skilled care then it could be up to 48 hours. He stated that he did not know he needed to contact the Ombudsman of all transfers and discharges. Page 1 of 2 675593 675593 11/01/2023 Wisteria Place 3202 S Willis St Abilene, TX 79605

F 0623 Record review of facility policy on 11/1/23 titled: Criteria for Transfer and Discharge revealed: Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Residents Affected - Few 675593 Page 2 of 2