Health inspection·January 4, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one (Resident #1) of five residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #1 when he planned discharge home on [DATE]. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home. Findings included: Record Review of Resident #1's admission face sheet dated 01/04/2024 reflected that he was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's active diagnoses included cerebral atherosclerosis, a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. hyperlipemia, a condition in which there are high levels of fat particles (lipids) in the blood. vascular dementia without behavioral disturbance, which occur due to problems with reasoning, panning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, glaucoma disease, rheumatoid arthritis, neuralgia, which is severe, sharp, often shock-like pain that follows the path of a nerve and neuritis, which is inflammation of the nerve, dyspnea, which was shortness of breath, myocardial infraction, which was caused by decreased or complete cessation of blood flow to a portion of the myocardium, history of ischemic attack, a temporary blockage of blood flow to the brain and cerebral infraction without residual deficits, restlessness and agitation. Record review of Resident 1's admission MDS assessment dated [DATE] reflected a BIMS score was a 3, which indicated he has severe cognitive impairment. BIMS is a brief cognitive screening measure that focuses on orientation and short-term word recall. Record review of Resident #1's Care Plan dated 11/30/2023 reflected a focus area with a plan on Resident #1 discharging home. Resident #1 will safely discharge home with Hospice. The Care Plan did not reflect a discharge planning for Resident #1 when initially reviewed for Record review and with a Page 1 of 3 675820 675820 01/04/2024 The Lennwood Nursing and Rehabilitation 8017 W Virginia Dr Dallas, TX 75237

F 0661 revision date of 01/04/2024 to reflect discharge planning. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Nursing Progress Note dated 12/09/2023 reflected, The resident discharged home via Transport x 2 Transport Drivers at this time. The resident's medications were sent with the resident . Residents Affected - Few In an interview on 01/04/2023 at 11:57 AM with SPS of Resident #1, she stated that Resident #1 was currently at home but was unavailable to speak due to his health issues. SPS stated that Resident #1 was a Respite Care resident at the facility and was only at the facility for a few weeks. SPS stated that Resident #1 was discharged from the facility home and confirmed that she did not receive any documentation from the facility regarding Resident #1's discharge from the facility. In an interview with the DON on 01/04/2024 at 2:45 PM she stated that Resident #1 was a Respite Care resident and was at the facility to give his wife, who was his caregiver a break. DON stated that Discharge Summary for Resident #1 should be in PCC under the Miscellaneous Tab. DON was informed that the Discharge Summary for Resident #1 was not in PCC. PCC is PointClickCare, a cloud-based Healthcare Software platform that connects care, services, and financial operations. DON reported that the MDS Coordinator or SW were responsible for completing and inputting the discharged Summaries for residents who discharged from the facility. DON stated that she would need to speak with the MDS Coordinator and SW to obtain more information as to where the Discharge Summary for Resident #1 was located. In an interview with the DON on 01/04/2024 at 2:52 PM, she reported that she spoke with the MDS Coordinator and was advised that the SW is responsible for completing the Discharge Summary for residents that are discharged from the facility. DON stated that she spoke with SW via telephone and was advised that Resident #1 was at the facility for a couple of weeks for Respite Care and would not have a Discharge Summary in his file due to him being admitted to the facility as a Respite Care resident. DON was informed that a Discharge Summary is needed for all residents that are discharged from the facility. DON stated that she informed the SW that a discharge summary will be needed for all residents that discharge from the facility. In an Interview with the ADM on 01/04/2024 at 4:15 PM, he acknowledged that discharge summaries should be completed for each resident that discharges from the facility including Respite Care residents. Respite Care provides short-term relief for primary caregivers. ADM reported that he thought that discharge summaries were being completed on all residents that have discharged from the facility. ADM stated that the DON will review records of discharged residents and ensure that discharge summaries are completed for all residents that discharge from the facility. In an Interview with the SW on 01/05/2023 at 3:53 PM revealed that she has been employed at the facility since August 2022. SW stated that Resident #1 was a Respite Care resident at the facility and was at the facility for a short period of time. SW stated that she completes discharge summaries for residents that discharge from the facility but has never done discharge summaries for residents that were at the facility for Respite Care. SW stated that she had a Care Plan Meeting with staff and Resident #1 and his family to discuss the plans for the family to care for Resident #1 at home. She reported that there was not a SW at the facility prior to her being employed and she was not directed by anyone at the facility not to complete a discharge summary for residents such as Resident #1 who were temporarily at the facility for Respite Care and discharged home. SW stated that she did not feel like there was any harm caused to Resident #1 or previous Respite Care residents that discharged home to the community due to the residents returning to their normal routine of being cared for by 675820 Page 2 of 3 675820 01/04/2024 The Lennwood Nursing and Rehabilitation 8017 W Virginia Dr Dallas, TX 75237

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few their caregivers. SW stated that on 01/04/2024, the DON had a discussion with her advising her that a Discharge Summary would need to be completed for each resident, including Respite Care residents and placed in the residents' file. Record review of Resident #1's Clinical Records reflected no discharge summary and reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). Record review of the facility's policy titled, Discharge Summary and Plan, revised December 2023, reflected, Policy Statement, when a resident's discharge is anticipated a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. 1. When. the facility anticipates a resident's discharge to a private residence, another nursing facility, a discharge summary wand post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of these resident's status at the time of discharge .The discharge summary shall include a description of the residents. a. Current diagnoses b. Medical history c. Course of illness 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. 13. A copy of the following will be provided to the resident .and a copy will be filed in the resident's medical records . a. an evaluation b. the post-discharge plan; and c. the discharge summary. 675820 Page 3 of 3