Health inspection·February 6, 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 interview and record review, 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 1 of 1 (Resident #1) residents reviewed for discharge rights. Residents Affected - Few The facility failed to document in Resident #1's chart actions made to ensure a safe and orderly discharge, and to find alternate placement for Resident #1. This failure placed residents at risk of being improperly discharged . Findings included: A record review of Resident #1's face sheet dated 2/06/2024 reflected a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of the body), vascular dementia (cognitive decline), epilepsy (seizure disorder), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), apraxia (neurological motor planning disorder), disorder of brain, hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), and cerebral infarction (stroke). A record review of Resident #1's MDS assessment type titled None of the above dated 1/03/2024 reflected she had severely impaired cognitive skills for daily decision making. A BIMS score, which is used to determine the severity of cognitive loss, was not reflected . Resident #1's MDS assessment reflected she had been discharged to the hospital and her return to the facility was anticipated. Section GG reflected Resident #1 utilized a wheelchair and was dependent on staff for all ADLs. A record review of Resident #1's care plan last revised on 1/08/2024 reflected she had impaired mobility and dementia. Resident #1's discharge goals, discharge preferences and discharge plans were not documented in her care plan. A record review of a written discharge notice addressed to Resident #1's family member dated 12/11/2023 reflected Resident #1 was being discharged from the facility on 1/09/2024 for non-payment and Medicaid ineligibility. The letter reflected, The facility staff will work with you to make preparations needed to ensure a safe and orderly transition and We have provided, and will continue to provide, assistance with placement in another community or at a home, if you so desire. A record review of Resident #1's progress notes dated 12/06/2023-1/03/2024 reflected no documentation of home health referrals, durable medical equipment requested or ordered, attempts to find alternate placement, or communications with the hospital in which Resident #1 was transferred to. There Page 1 of 9 675649 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0624 were no social services notes documented in Resident #1's progress notes from 12/06/2023-1/03/2024. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #1's physician Discharge summary dated [DATE] reflected Resident #1 was discharged to the hospital on 1/03/2024 for evaluation and treatment. The social service discharge summary signed by the SW on 1/08/2024 reflected no referrals were made to home health agencies, meals-on-wheels, or senior citizen agencies. The nursing discharge summary signed by the ADON on 1/08/2024 reflected Resident #1's reason for discharge was hospitalization-financial reasons were not indicated as the reason for discharge. Residents Affected - Few A record review of Resident #1's progress note dated 12/06/2023 authored by the Administrator reflected she had spoken to Resident #1's family member advising of the anticipated discharge date of 1/04/2024 due to non-payment and failure to qualify for Medicaid. This progress note reflected the following: Educated on date, location, DME to order, and confirmation to refer for home health services. [Resident #1's family member] verbalized understanding and provided updated address for communication and DC location. Understood ability to appeal DC actions or bring account to current to pause DC procedures. A record review of written correspondence from Resident #1's family to an HHSC surveyor dated 2/08/2024 reflected Resident #1 had been discharged from the hospital to a different nursing facility on 1/12/2024. During an interview on 2/05/2024 at 11:22 a.m., Resident #1's family stated Resident #1's Medicaid had been denied for the first time in eight years, the facility was not willing to work with them on payment, and there was no communication. Resident #1's family stated Resident #1 was a quadriplegic, had dementia and was non-verbal. Resident #1's family stated had Resident #1 not gone to the hospital unexpectedly to get a feeding tube, the facility would have dropped Resident #1 off at their home where they would have needed to refuse her due to not being able to take care of her. Resident #1's family said Resident #1's Medicaid was pending, and the facility would not allow her to return after her hospitalization due to her Medicaid-pending status. Resident #1's family stated Resident #1 went to a new facility after being discharged from the hospital and that facility had been making attempts to fix Resident #1's issue with Medicaid. During an interview on 2/06/2024 at 12:32 p.m., the BOM stated she had provided several discharge notices to Resident #1's family for non-payment, and the most recent notice was given in December of 2023. The BOM stated Resident #1 was denied Medicaid due to her income being too high, and she would have needed to have a qualified income trust. The BOM stated she had communicated that to Resident #1's RP. The BOM stated Resident #1's RP applied for Medicaid himself per his wishes, and that usually the facility preferred to handle the applications to help catch things. During an interview on 2/07/2024 at 1:59 p.m., the SW stated the discharge process began the day a resident received a discharge notice. The SW stated the discharge process was an effort involving therapy, social services, and nursing. The SW stated the process was documented in the physician's discharge note and the discharge summary. The SW stated she started the discharge summary then Medical Records started the physician discharge note. The SW stated she was not aware Resident #1 was given a discharge notice and correct that there was not much she could have done to ensure a safe discharge if she was unaware of the facility-initiated discharge. The SW stated Resident #1 went to the hospital and from there, the hospital handled her discharge. The SW stated she did not know why Resident #1 had not returned to the facility. The SW stated she had not made any attempt to find alternate 675649 Page 2 of 9 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0624 Level of Harm - Minimal harm or potential for actual harm placement for Resident #1 because Resident #1 had gone to the hospital. The SW stated if residents were not given alternate placement or if they were not safe to be at home, her assumption was that without having the proper care, they would return to the hospital. The SW stated she did not know why she was not made aware of Resident #1's facility-initiated discharge and said yes she would expect that information to have been communicated to her. Residents Affected - Few During an interview on 2/06/2024 at 2:34 p.m., Resident #1's family stated after Resident #1 went to the hospital on 1/03/2024. Resident #1's famly stated a case worker from the hospital called him and told him that Resident #1 was no longer allowed at the facility, but did not say why. Resident #1's family stated the Administrator had told him Resident #1 was not allowed back to the facility due to non-payment. Resident #1's family stated that at that time, Resident #1's Medicaid application was pending. Resident #1's family stated the facility did not try to ensure a safe discharge or locate alternate placement, and they made the hospital do it. Resident #1 stated he would expect the discharge planning to occur a few weeks prior to the schedule discharge date . During an interview on 2/06/2024 at 2:59 p.m., the DON stated We usually make sure they have home health, equipment, and communicate with the family. The DON stated We talk to the family and the family chooses what they want as far as alternate placement. The DON stated they would consult with the MPOA to find alternate placement. The DON stated no Resident #1 was not able to care for herself. The DON stated in order to obtain the correction information as to why Resident #1 did not return to the facility after being hospitalized , the HHSC surveyor would need to speak with the Administrator. The DON stated she thought in the morning meeting that the Administrator and SW mentioned they would set up home health for Resident #1. When asked what could happen if a resident was discharged unsafely or without attempts to find alternate placement, the DON stated she could not answer that because usually they tried to ensure discharges were safe. During an interview on 2/06/2024 at 4:30 p.m., the Administrator stated Resident #1 was not permitted to be readmitted to the facility after being hospitalized due to Resident #1 being given a 30-day discharge notice for non-payment. The Administrator stated Resident #1 was discharged acutely due to a UTI. The Administrator stated communications for Resident #1's discharge planning were verbal between herself and Resident #1's family. The Administrator stated she thought Resident #1's family was going to come by the facility and pay the balance prior to the execution of the 30-day notice, and so Resident #1's discharge was not anticipated . A record review of the facility's policy titled Transfer or Discharge, Facility-Initiated dated October 2022 reflected the following: Policy Statement Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Policy Interpretation and Implementation I. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: e. the resident has failed, after reasonable and appropriate notice, to pay for ( or to have paid 675649 Page 3 of 9 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0624 under Level of Harm - Minimal harm or potential for actual harm Medicare or Medicaid) a stay at this facility. Residents Affected - Few (1) Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. 2. Transfer and discharge includes movement of a resident from a certified bed in the facility to a noncertified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. Facility-Initiated Transfer or Discharge I. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-Payment as a Basis for Discharge 1. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. when the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. after the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. 2. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. 3. In situations where a resident representative has failed to pay, the facility may discharge the resident for nonpayment; however, if there is evidence of exploitation or misappropriation of the resident's funds by the representative, the facility will take steps to notify the appropriate authorities on the resident's behalf, before discharging the resident. Notice of Transfer or Discharge (Planned) I. Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility. 675649 Page 4 of 9 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0624 2. The resident and representative are notified in writing of the following information: Level of Harm - Minimal harm or potential for actual harm e. The Notice of Facility Bed-Hold and policies; Residents Affected - Few 5. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification and permit adequate time for discharge planning. Notice of Transfer or Discharge (Emergent or Therapeutic Leave) I. When residents who are sent emergent [NAME] to an acute care setting, these scenarios are considered facility initiated transfers, NOT discharges, because the resident's return is generally expected. 2. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility. 5. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 7. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Notice of Discharge after Transfer I . If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). 2. If the facility does not permit a resident's return to the facility ( i.e., initiates a discharge) based on inability to meet the resident's needs, the facility will notify the res ident, and/or his or her representative in writing of the discharge, including notification of appeal rights. Orientation for Transfer or Discharge (Planned) I. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. 2. A member of the interdisciplinary team will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 3. Sufficient preparation and orientation for the resident prior to an immediate facility-oriented transfer or discharge includes explaining to the resident where he/she is going and why, and taking steps to minimize his/her anxiety or depression (e.g., working with the resident, representative, or family to ensure that the resident's be longings will be taken care of and transferred to the new location as needed/requested. And ensuring that staff recognize characteristic resident reactions identified during assessment and care 675649 Page 5 of 9 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0624 planning). Level of Harm - Minimal harm or potential for actual harm 5. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Residents Affected - Few Documentation of Facility- Initiated Transfer or Discharge 4. If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to: a. determine if the resident still requires the services of the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services; b. ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by facility staff to the hospital; c. find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide the treatments, medications, and services needed, the facility may not be able to meet the resident's needs: and d. work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge. 675649 Page 6 of 9 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, 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 1 of 1 (Resident #1) residents reviewed for discharge rights. The facility failed to provide their bed hold policy to Resident #1 or her RP, in writing, upon Resident #1's discharge from the facility on 1/03/2024. This failure placed residents at risk of being improperly discharged . Findings included: A record review of Resident #1's face sheet dated 2/06/2024 reflected a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of the body), vascular dementia (cognitive decline), epilepsy (seizure disorder), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), apraxia (neurological motor planning disorder), disorder of brain, hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), and cerebral infarction (stroke). A record review of Resident #1's MDS assessment type titled None of the above dated 1/03/2024 reflected she had severely impaired cognitive skills for daily decision making. A BIMS score, which is used to determine the severity of cognitive loss, was not reflected . Resident #1's MDS assessment reflected she had been discharged to the hospital and her return to the facility was anticipated. Section GG reflected Resident #1 utilized a wheelchair and was dependent on staff for all ADLs. A record review of Resident #1's care plan last revised on 1/08/2024 reflected she had impaired mobility and dementia. Resident #1's discharge goals, discharge preferences and discharge plans were not documented in her care plan. A record review of a written discharge notice addressed to Resident #1's family member dated 12/11/2023 reflected Resident #1 was being discharged from the facility on 1/09/2024 for non-payment and Medicaid ineligibility. The letter reflected, The facility staff will work with you to make preparations needed to ensure a safe and orderly transition and We have provided, and will continue to provide, assistance with placement in another community or at a home, if you so desire. A record review of Resident #1's physician Discharge summary dated [DATE] reflected Resident #1 was discharged to the hospital on 1/03/2024 for evaluation and treatment. A record review of Resident #1's progress note dated 12/06/2023 authored by the Administrator reflected she had spoken to Resident #1's family member advising of the anticipated discharge date of 1/04/2024 due to non-payment and failure to qualify for Medicaid. This progress note reflected the following: Educated on date, location, DME to order, and confirmation to refer for home health services. [Resident #1's family member] verbalized understanding and provided updated address for communication and DC location. Understood ability to appeal DC actions or bring account to current to pause DC procedures. 675649 Page 7 of 9 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of written correspondence from Resident #1's family to an HHSC surveyor dated 2/08/2024 reflected Resident #1 had been discharged from the hospital to a different nursing facility on 1/12/2024. During an interview on 2/05/2024 at 11:22 a.m., Resident #1's family stated Resident #1's Medicaid had been denied for the first time in eight years, the facility was not willing to work with them on payment, and there was no communication. Resident #1's family said Resident #1's Medicaid was pending, and the facility would not allow her to return after her hospitalization due to her Medicaid-pending status. Resident #1's family stated Resident #1 went to a new facility after being discharged from the hospital and that facility had been making attempts to fix Resident #1's issue with Medicaid. During an interview on 2/06/2024 at 12:32 p.m., the BOM stated she had provided several discharge notices to Resident #1's family for non-payment since June of 2023, and the most recent notice was given in December of 2023. The BOM stated Resident #1 was denied Medicaid due to her income being too high, and she would have needed to have a qualified income trust. The BOM stated she had communicated that to Resident #1's RP. The BOM stated Resident #1's RP applied for Medicaid himself, without the facility's help, per his wishes, and that usually the facility preferred to handle the applications to help catch things. During an interview on 2/07/2024 at 1:40 p.m., the Administrator stated she was not sure whether the facility's bed hold policy was communicated to Resident #1 or Resident #1's RP at the time Resident #1 was transferred to the hospital . During an interview on 2/07/2024 at 1:59 p.m., the SW stated the discharge process began the day a resident received a discharge notice. The SW stated she was not aware Resident #1 was given a discharge notice and correct that there was not much she could have done to ensure a safe discharge if she was unaware of the facility-initiated discharge. The SW stated Resident #1 went to the hospital and from there, the hospital handled her discharge. The SW stated she did not know why Resident #1 had not returned to the facility. During an interview on 2/06/2024 at 2:34 p.m., Resident #1's family stated no the facility had not provided a copy of their bed hold policy. During an interview on 2/06/2024 at 2:59 p.m., the DON stated she could not answer as to what the policy was for communication of the facility's bed hold policy to residents and their representatives. The DON stated the Administrator could answer better. The DON stated there was a bed hold for when residents wanted to come back, and it's related a lot to the business office. During an interview on 2/06/2024 at 4:30 p.m., the Administrator stated Resident #1 was not permitted to be readmitted to the facility after being hospitalized due to Resident #1 being given a 30-day discharge notice for non-payment. The Administrator did not clarify whose responsibility it was to issue a copy of the facility's bed hold policy to residents when they were discharged . A record review of the facility's undated document titled Bed Hold Procedure reflected the following: PURPOSE: 675649 Page 8 of 9 675649 02/06/2024 Stonebridge Health Rehab 11127 Circle Dr Austin, TX 78736

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few To inform the resident/responsible party of the facility Bed Hold Policy and to give the resident/responsible party the option to hold the bed for the resident if he/she should have a hospital stay or leave on pass. POLICY: All residents/responsible parties must be informed and given the option to pay for bed hold if the resident should have a hospital stay or leave on pass. Every resident/responsible party must complete the Bed Hold Policy form at the time of admission. The Bed Hold Policy Initiation must be completed each time ethe Bed Hold is initiated. PROCEDURE: 1. Review with the resident/responsible party the Bed Hold Policy. Explain the facility's bed hold charges upon admission. 2. Inform the resident/responsible party that each time the resident is admitted to the hospital or leaves from the facility, they must sign or give verbal approval to a facility representative to either hold or release the bed. 3. If the resident/responsible party chooses to hold the bed, write in the resident's name and the daily amount of the bed hold charge. Have them initial their choice. 4. If the resident/responsible party chooses not to hold the bed, fill in the resident's name and have them initial their choice. 5. Have the resident/responsible party sign and date the Bed Hold Policy form. 675649 Page 9 of 9