Health inspection·March 20, 2024

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 notify a representative of the Office of the State Long-Term Care Ombudsman, for 1 of 3 residents (Resident #1) reviewed for discharge. The facility initiated a 30-day discharge for Resident #1 on 03/06/24 and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 03/20/24, indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), stroke, and high blood pressure. The resident was discharged on 03/08/24. Record review of Resident #1's quarterly MDS assessment, dated 02/05/24, indicated Resident #1 understood and understood others. Resident #1's BIMS score was 15, which indicated he was cognitively intact. Resident #1 required assistance with bed mobility, transfer, and toileting and was independent with eating. Record review of Resident # 1's comprehensive care plan, dated 4/4/22, indicated Resident #1 had an ADL self-care deficit related to activity intolerance, hemiplegia, and impaired balance. Record review of Resident # 1's comprehensive care plan, dated 11/21/22, indicated he anticipated he would be a long-term care resident. Record review of Resident #1's progress notes, dated 03/07/24 charted by the Social Worker, reflected, that after discussing the resident discharge notice with the resident and family, SW researched and identified three shelters in the local downtown Dallas area that accepted men. SW identified Shelter A as a safe place to discharge due to the support services offered including access to healthcare via a local hospital partner, emergency day and night shelter, transitional housing, and case management. SW contacted Shelter A for eligibility requirements and availability. SW advised Resident #1 that he needed to be at the Intake Department by 6:00 am for processing and bed assignment. All information was conveyed to Resident #1 and his family who agreed to the discharge plan. Page 1 of 15 675879 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0623 Record review of Resident #1's chart did not reveal any notification to the Ombudsman. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's progress notes, dated 03/08/24, charted by LVN A reflected, discharged via facility van to shelter A. Meds and belongings with the resident. Residents Affected - Few During an interview on 03/18/24 at 4:24 p.m., The Ombudsman said she was not aware of Resident #1's 30-day discharge notice or that he was discharged from the facility. During an interview on 03/20/24 at 11:30 a.m., the ADON said she was aware the Ombudsman was supposed to be notified but she thought the SW notified them. She said it was important to notify the Ombudsman of any concerns they may have at the facility so they could help with placement or other options. The ADON said after the in-service given on 03/19/24 she was aware she needed to be part of the discharge process of notifying the Ombudsman and physician of any 30-day discharges. During an interview on 03/20/24 at 3:10 p.m., the SW said she had been a SW for years but was not aware she needed to notify the Ombudsman for a 30-day notice. She said she was unaware of who notified the Ombudsman before the in-service given on 03/19/24. She said she now knows to notify the Ombudsman and physician when a resident receives a 30-day discharge. During an interview on 03/20/24 at 5:24 p.m., the AIT Administrator said she was aware the ombudsman needed to be notified of a 30-day discharge but thought the SW notified them. She said after the in-service given on 03/19/24 she was aware she needed to notify the Ombudsman and physician of any 30-day discharge. Record review of the facility's policy titled, Transfer or Discharge Notice, reviewed January 2023, indicated, Policy statement Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge . 2. Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility 3. Expect as specified below, the resident and his or her representative to be given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility. 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. the safety of individuals in the facility would be endangered; b. The health of individuals in the facility would be endangered; c. The resident's health improves sufficiently to allow a more immediate transfer or discharge; d. An immediate transfer or discharge is required by the resident's urgent medical needs; and/or e. The resident has not resided in the facility for thirty (30) days. 5. The resident and representative are notified in writing of the following information: the specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. an explanation of the resident's rights to appeal the transfer or discharge to the state . 6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 8. The reasons for transfer or discharge are documented in the resident's medical record . 675879 Page 2 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and document an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 3 residents reviewed for discharges. Residents Affected - Few The facility failed to ensure Resident #1 had a safe discharge leading to his hospitalization and threats of suicide on 03/08/24. An IJ was identified on 03/19/24. The IJ template was provided to the facility on [DATE] at 4:40 p.m. While the Immediate Jeopardy was removed on 03/20/24 at 5:39 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy with potential for more than minimal harm because all staff had not been trained on proper discharge planning with the facility's continuation of in-servicing and monitoring the Plan of Removal. This failure placed residents at risk of unsafe discharges, worsened health conditions, and hospitalizations. The findings included: Record review of Resident #1's face sheet, dated 03/20/24, indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), stroke, and high blood pressure. Record review of Resident #1's quarterly MDS assessment, dated 02/05/24, indicated Resident #1 understood and understood others. Resident #1's BIMS score was 15, which indicated he was cognitively intact. Resident #1 required assistance with bed mobility, transfer, and toileting and was independent with eating. The MDS did not indicate any mood or behavior concerns. Record review of Resident # 1's MAR dated 03/01/24 through 03/31/24 indicated: Haloperidol Oral Tablet 20 MG (Haloperidol) Give 1 tablet by mouth at bedtime related to Psychotic Disorder with Delusions. Record review of Resident # 1's MAR dated 03/01/24 through 03/31/24 indicated: Cymbalta Oral Capsule Delayed-Release Particles 60 MG (Duloxetine HCI) Give 1 capsule by mouth in the morning for mood. Record review of Resident # 1's comprehensive care plan, dated 4/4/22, indicated Resident #1 had an ADL self-care deficit related to activity intolerance, hemiplegia, and impaired balance. Record review of Resident # 1's comprehensive care plan, dated 11/21/22, indicated he anticipated he would be a long-term care resident. Resident #1 was dependent on staff to meet his emotional, intellectual, physical, and social needs related to his immobility and physical limitations. Resident #1 required the use of Haldol (an antipsychotic medication) related to his diagnosis of schizophrenia. 675879 Page 3 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident # 1's comprehensive care plan dated 1/23/24 indicated Resident #1 had depression. He took Cymbalta (a medication used to treat depression). Record review of Resident # 1's EMR reflected he was discharged on 03/08/24 at 4:45 am. Record review of Resident # 1's EMR did not reveal any behaviors from 02/18/24 through 03/07/24. Residents Affected - Few Record review of Resident # 1's Hospital history and physical dated 03/08/24. Resident #1 said he would use a gun to kill other people and himself and that the gun was in his family member's apartment. He was discharged to a shelter form the nursing home but felt it was not feasible for him given that the shelter didn't have the support to assist him with his ADLs. Resident #1 reports that these events led to his current psychiatric symptoms and presented to the ER for further evaluation. During a phone interview on 03/18/24 at 10:18 a.m., the hospital social worker said Resident #1 presented to the local hospital with suicidal ideations after being discharged from the nursing home on [DATE]. The hospital social worker said Resident #1 was left on the side of the road waiting to enter a shelter, but the shelter would not accept him because he required help with his ADLs. The hospital social worker said Resident #1 was not able to remember how or when to take his medications. He said the facility did not provide an adequate and safe discharge for Resident #1. During an interview on 03/18/24 at 4:24 p.m., the Ombudsman said she was not aware of Resident #1's 30-day discharge notice or that he was discharged from the facility. During a phone interview on 03/18/24 at 5:10 p.m., Resident #1 said he was aware of the 30-day letter the facility had given him because of some altercations he had with other residents in the facility. He said he was aware he was going to a shelter but he was under the impression that he was accepted to the shelter. He said the facility told him about standing in line for intake but he thought that was just a formality. He said he waited in line and when they talked with him at the shelter, they told him he would not be accepted because he required help with his care and wore briefs. He said he did not know what to do. It was cold and had started raining, so he wheeled himself to the train station that was nearby and then went to the local hospital. He said he told the admitting doctor that if he had to be homeless, he would shoot himself. He said he meant it. He said he would not have agreed to go to the homeless shelter if he had known he was not accepted. During a phone interview on 03/19/24 at 9:00 a.m., Social Worker D over the intake department at the shelter said she never talked to a facility about Resident #1. She said if she or any other staff member of the shelter talked with a nursing home staff member, their first question would have been, Could he/she do everything for themselves? She said the shelter was about 3 acres and they did not have the staff to ensure people who required help would be taken care of. She said they only accepted guests (what they call people who were accepted to the shelter) who were self-sufficient for themselves. She said if they accepted guests who required assistance with their ADLs, they would be liable for their care. She said most people have a misconception about a homeless shelter. She said the guests must be able to do for themselves which included getting down to a bed on the floor and getting up to go to the bathroom located outside of where they slept. She said they had to go to the dining area for a meal and to the shower room themselves. She said her intake staff were nurses and knew what questions to ask. She said the people who called them for intakes did not always give truthful answers and that was why they screened guests before they accepted them. She said if Resident #1 required help, he was denied admission to the shelter. She said she did not remember Resident #1 or what might have happened to him after he was denied admission. She said they had at least 600 intakes a 675879 Page 4 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few day but could only accept 300 a day. She looked in her electronic system and email for a referral on Resident #1 and said she did not see any emails, or a chart made for Resident #1. She said their goal was to provide food and shelter. She said if they were full or a person was not accepted, they would offer other options with other shelters in the area. The social worker said the closest train station was about a half mile away from the shelter. During a phone interview on 03/19/24 at 10:40 a.m., Resident #1's RP said the facility had called her and told her about the 30-day discharge letter. She said they asked if he could live with her and she said he could not. They asked about other family members or friends and he did not have any that were able to meet his needs. She said they did tell her about the shelter but she thought he would be admitted . She said she did not have much knowledge about the shelter but thought it was okay since the social worker at the facility made the recommendations. She said she was not aware the facility would just drop him off and leave him there. During a phone interview on 3/19/24 at 11:06 a.m., the SW of the facility said Resident #1 had been given a 30-day notice. She said they had been looking for another facility to accept him for an unknown amount of time before they issued the 30-day notice. She said she had called several facilities but they had all denied him. She said she called 3 shelters and one of the shelters seemed to fit his needs. She said he told her he would like to get help with independent living. She said she called the shelter, gave the information they asked for, and told her he needed to be at the shelter by 6:00 am for intake. She said she asked the nursing staff to have him ready and at the shelter by 6:00 am. She said the intake person told her he needed to have some form of independence and he did. She said she read the website and felt he would be a suitable candidate for the shelter since they had counselors on staff and partnered with the local hospital, they could help him better transition into an independent life. She said she was not aware of how shelters worked. She said she thought Resident #1 needed staff assistance x1 with grooming and wore briefs. She said the facility made sure he had some briefs available when he left the facility. During an interview on 3/19/24 at 11:30 a.m., the ADON said she was not directly involved in Resident #1's discharge. She said the SW was over the discharge process. She said she had asked the social worker about Resident #1's discharge and asked her if she thought she had done a safe discharge and the SW indicated she did. She said at the time she asked the SW she was not aware Resident #1 was not accepted to the shelter but did not know much about the shelter and its guidelines. During an interview on 3/19/24 at 12:45 p.m., the AIT Administrator said they had given Resident #1 a 30-day discharge notice because of his behaviors and failure to comply with facility policies. She said she had given the letter to Resident #1 and he was able to read and ask questions. She said afterwards she signed the 30-day letter. She said they had placed him on 1 on 1 monitoring as they searched for other facilities. She said she was told by the SW that the other facilities had denied him. She said the SW was making all the discharge plans for Resident #1. She said she was aware of the discharge to the shelter but was unaware of their guidelines. During an interview on 3/19/24 at 12:52 p.m., the RDO said the facility does not have a policy on 30-day notices. He said they issued the letter, and if the family and the resident agreed then they discharged before the 30-day. He said he was not personally involved with the discharge process with the shelter for Resident #1, but he believed the SW was managing the process. During a phone interview on 3/19/24 at 1:38 p.m., the Medical Director said he was not notified of Resident #1's discharge until the surveyor questioned him about his discharge. He also said he was 675879 Page 5 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few unfamiliar with the rules of a homeless shelter. He said if the shelter said he needed to be independent then a shelter would not be a safe discharge. He said the facility might have reached out to his NP. He said to call the NP. During a phone interview on 3/19/24 at 1:55 p.m., the NP said she could not remember if the facility notified her of Resident #1's discharge. She looked through her phone and said she did not have a text from the facility about Resident #1's discharge. The NP said she was unaware of Resident #1 being discharged to a homeless shelter. She said she was not sure if Resident #1 would know how to take his medications properly but knew he could not live independently in a shelter. She said he required the assistance of 1 staff member for his ADL care. During a phone interview on 3/19/24 at 4:45 p.m., LVN A said she was the nurse who released Resident #1. She said she did not call a report to the homeless shelter, do medication teaching, have a doctor's order to discharge, or do a discharge summary for Resident #1. She said she was under the impression the shelter was aware he was coming. She said she did not think about teaching him about his medications or doing a discharge summary. She said she was unsure if she had notified the doctor related to Resident #1's discharge. LVN A said she knew she was supposed to educate the resident about his medication and notify the doctor of his discharge. LVN A said she was able to see how all these things needed to be done for the continuation of his care. During a phone interview on 3/19/24 at 4:53 p.m., Van Driver B said he took Resident #1 along with CNA C to the shelter on the morning of 03/08/24. He said he was told to have him at the shelter for intake at about 6:00 am. He said CNA C went inside to let the shelter know Resident#1 was outside, and they left. He said it was cold that morning but Resident #1 had on a jacket. Van Driver B said he was not aware Resident #1 was not accepted into the shelter. He said he would have never left him if he knew he was not accepted. Record review of the 30-day discharge letter dated 03/06/24 signed by AIT Administrator. The letter was addressed to Resident #1 RP and stated, This is to inform you that Resident #1 is being discharged from this facility. The reason for discharge, in accordance with federal regulations, is as follows: [X] the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; Resident has had infarctions regarding destruction of property, unsafe use of his motorized wheelchair, theft and smoking in the facility.[ X] the safety of individuals in the facility is endangered; Resident has had multiple infarctions regarding physical and verbal aggression towards other residents, theft and smoking inside the facility. The effective date of discharge is April 6, 2024. Record review of the facility's policy titled, Transfer or Discharge Notice, reviewed January 2023, indicated, Policy statement Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge . 2. Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility3. Expect 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. 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. the safety of individuals in the facility would be endangered; b. The health of individuals in the facility would be endangered, c. The resident's health improves sufficiently to allow a more immediate transfer or discharge; d. An immediate transfer or discharge is required by the resident's urgent medical needs; and/or e. The resident has not resided in the facility for thirty (30) 675879 Page 6 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few days. 5. The resident and representative are notified in writing of the following information: a. the specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. an explanation of the resident's rights to appeal the transfer or discharge to the state; f. The name, address, and telephone number of the Office of the State Long-term care ombudsman .; 6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 7. Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals . 8. The reasons for transfer or discharge are documented in the resident's medical record Record review of the facility's policy titled, Transfer or Discharge Documentation and Notice, reviewed January 2023, indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provide. 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless- a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; 4. When a resident is transferred or discharged because his or her needs cannot be met at the facility, documentation will include: (a) the specific resident needs that cannot be met; (b)this facility's attempt to meet those needs; and (c) the receiving facility's service(s) that are available to meet those needs. b. That an appropriate notice was provided to the resident and/or legal representative, c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medical, physical, and mental condition; g. Disposition of personal effects; a. disposition of medications; i-others as appropriate or as necessary; and j. The signature of the person recording the data in the medical record. 5. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's attending physician: a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility or b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. 6. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by a physician: a. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, or b. The health of individuals in the facility would otherwise be endangered. 7. Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: a. The basis for the transfer or discharge . b. Contact information of the practitioner responsible for the care of the resident; c. Resident representative information including contact information; d. Advance directive information; e. All special instructions or precautions for ongoing care, as appropriate; f. Comprehensive care plan goals; and g. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The AIT Administrator was notified on 03/19/24 at 4:39 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 03/19/24 at 4:40 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 03/20/24 at 12:21 p.m. and included the following: Resident #1 was no longer a resident at the facility as of March 8, 2024. 675879 Page 7 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 Administrator notified Medical Director of IJ on 03-19-2024. Level of Harm - Immediate jeopardy to resident health or safety Ad hoc QAPI (off cycle meeting) completed with the Medical Director on 03-19-2024. Residents Affected - Few The regional SW/LNFA conducted in-service with facility IDT team that included the SW regarding ensuring safe discharges on 03-19-2024. This training included transfer and discharge requirements (being aware of residents' needs when discharging and validating the accepting provider is appropriate), documentation and appropriate notifications. Facility administration/SW are responsible for discharge planning/notices. Ombudsman notified of IJ on 03-19-2024. Administrator/designee to in-service all staff (including C.N.A.'s, housekeeping and dietary) on safe discharging, including accepting facility, medications. The staff may be approached by a resident at a given time regarding a desire to discharge and they will have an understanding of what that may entail. This training began on 03-19-2024. This will be completed on 03-20-2024. Staff that may be out on leave will be in-serviced remotely. ADON to complete audit on 03-19-2024 of residents that have been discharged since March 8, 2024, to ensure they were discharged safely. This audit will include an audit of any residents expected to discharge in the near future. There are no other residents with a 30-day discharge notice currently. Nursing staff will be retrained by ADON on 03-19-2024 regarding medical director notification on discharges. The administrator/ADON have been re-trained by RDO on ombudsman notification on 03-19-2024. Monitoring: In interviews on 03/20/24 from 1:00 p.m. until 5:29 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 6 am-2 pm shift 1 LVN (LVN P), 2 RNs (RN L, RN M), 1 MA (MA T), and 2 CNAs (CNA Y, CNA ZZ, and CNA EE), 2 pm-10 pm 1 LVN (LVN O), 2 RNs (RN K and RN N),1 MA (MA V), and 3 CNAs (CNA BB, CNA CC and CNA DD), 10 pm-6 am 1 LVN (LVN FF), and 2 CNAS (CNA X and CNA C). Dietary staff 2 Cooks (Cook KK and [NAME] MM), 3 kitchen aides (Kitchen Aide LL, Kitchen Aide MM, and Kitchen Aide OO), housekeeping department 4 housekeepers (Housekeeper E, Housekeeper M, Housekeeper F, and Housekeeper G), Therapy Department 5 therapist (DOR GG,PT HH, PT PP, PT, and OT II) and the ADON, MDS, SW, HR, Dietary Manager, and the Activity Director all who indicated they had received a written in-service regarding the process of safe discharges (such as what to do: who to notify, when to do it and how to complete the process for a resident who was planning on discharging from the facility). They verbalized they understood the discharge process. During an interview on 03/20/24 at 2:27 p.m., the Ombudsman said she was aware of the IJ received by the facility related to the unsafe discharge of Resident #1. During an interview on 03/20/24 at 2:34 p.m., the Medical Director said he was aware of the IJ received by the facility related to the unsafe discharge of Resident #1. During an observation and interview on 03/20/24 at 4:34 p.m., the ADON completed an audit of the 675879 Page 8 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few discharges of residents since 03/08/24 which included 7 residents, and all the residents had a safe discharge. The ADON and the surveyor reviewed the audit sheet. She indicated no further discharges were planned and no 30-day discharge notices were pending. Record review of an in-service training report dated 03/19/24, Topic: Discharge Planning Process given by the AIT Administrator to all staff indicated, The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals effectively and transitional them to post-discharge care. Identify specific discharge needs, involve the IDT team, notify the resident's physician, notify the ombudsman, and ensure an acceptable provider is appropriate for the resident. The in-service was reviewed and revealed that 52 staff members had signed. Record review of an in-service training report dated 03/19/24, Topic: Safe Discharge Process given by the Regional Social Worker to the IDT indicated, F624 provide examples that serve as good reminders of things not to forget. This includes working with the resident representative slash family to ensure that all of the resident's possessions are not lost or left behind. Facilities also must explain to the residents why they are going to another location or leaving the facility and must ensure that staff handle these transfers or discharges in a way that minimizes the resident's anxiety or depression. The staff must be able to recognize a resident's reaction that has been identified by the resident's assessment and care plan. The in-service was reviewed and revealed that 7 management members had signed.

F622-When the facility transfers or discharges a resident under any of the circumstances specific in paragraphs (C) (1) (i) (A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical records and appropriate information is communicated to the receiving healthcare institution or provider. i. Documentation in the resident's medical record must include. A. The basis for the transfer per paragraph C1I of this section. B. In the case of paragraph (C) (1) (i) (A) of this section, the specific resident's need that cannot be met, the facility attempts to meet the resident's need, and the service available at the facility to meet the need. ii. The documentation required by paragraph C2I of this section must be made byA. The resident physician when transferred or discharged is necessary under paragraph (C) (1) (A) or (B) of this section; And B. A physician when transferred or discharged is necessary under paragraph (C) (1) (I) (C) or(D) of this section. iii. Information provided to the receiving provider must include a minimum of the following: 675879 Page 9 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 B. Contact information of the practitioner responsible for the care of the resident Level of Harm - Immediate jeopardy to resident health or safety C. Resident representative information including contact information. Residents Affected - Few E. All special instructions or precautions for ongoing care, as appropriate. D. Advance Directive information F. Comprehensive care plan goals. G. All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21 (c) (2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. Record review of an in-service training report dated 03/19/24, Topic: Safe Discharge Notification was given by RDO to the AIT Administrator and the ADON. They discussed ensuring the whole discharge process was complete and accurate. They ensured the physician and the Ombudsman were notified of any discharges. Record review of an in-service training report dated 03/19/24, Topic: Discharge given by ADON to all nurses, indicated, When we discharge residents, only the physician nurse practitioner or physician assistant can give you orders. You are not to take orders from anyone else. When a discharge is being worked on the nurse should follow up with the physician and document, write discharge orders, and open the discharge summary. The in-service was reviewed and revealed that 11 nurses had signed. Record review of the QAPI meeting dated 03/19/24, signed by the MDS, DOR, ADON, AIT Administrator, SW, DM, and medical director on the phone. During an interview on 03/20/24 at 5:14 p.m., the ADON said all residents who would be discharged must be discharged to a safe place. She said the doctor should be notified so that the nurses could receive an order to discharge the resident. She said nurses must document all pertinent information about where the resident was going, and how he/she traveled (to other facility or home). She said they must call a report to the other entity to ensure they would be able to meet the resident's needs. She said all the above information must be documented in the resident's chart. She said that the nurses would start a discharge summary for each resident they discharged . She said she was part of the discharge process for the residents who had received a 30-day notice. The ADON said she and the Administrator were responsible for notifying the Ombudsman and the physicians of potential 30-day discharges. She said she was given an in-service by the Regional Social Worker and RDO administrator about the discharge process. During an interview on 03/20/24 at 5:24 p.m., the AIT Administrator said she was part of the discharge process. She said she was to ensure the transfer was documented in the nurses' notes and the receiving facility could meet the residents' needs. She said the nursing staff were to notify the physician and the family. She said the IDT should have a care plan structured with goals and ongoing care. She said she was responsible for notifying the Ombudsman and the Medical Director. On 03/20/24 at 5:29 p.m., the AIT Administrator was informed the IJ was removed: however, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete 675879 Page 10 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0660 in-service training and evaluate the effectiveness of the corrective systems Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 675879 Page 11 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 3 of 5 residents (Residents #1, #2 and #3) reviewed for discharge summaries. The facility failed to write an order for discharge, complete a discharge summary, and a reconciliation of medications for Resident #1 when he was discharged on 03/08/24. The facility failed to write an order for discharge and complete a discharge summary for Resident #2 and Resident #3. These failures could place residents at risk for a lack of continued care and services. Findings included: Record review of Resident #1's face sheet, dated 03/20/24, indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), stroke, and high blood pressure. Record review of Resident #1's quarterly MDS assessment, dated 02/05/24, indicated Resident #1 understood and understood others. Resident #1's BIMs score was 15, which indicated he was cognitively intact. Resident #1 required assistance with bed mobility, transfer, and toileting and was independent with eating. Record review of Resident # 1's comprehensive care plan, dated 4/4/22, indicated Resident #1 had an ADL self-care deficit related to activity intolerance, hemiplegia (complete or partial loss of function), and impaired balance. Record review of Resident #1's progress note, dated 03/08/24, charted by LVN A reflected: . discharged via facility van to a shelter. Meds and belongings with the resident Record review of Resident #1's EHR did not reveal a medication reconciliation of his medications. Record review of Resident #1's EHR reflected there was no discharge summary on 03/08/24. Record review of Resident #1's physician's orders reflected there was no discharge order on 03/08/24. During a phone interview on 3/19/24 at 4:45 p.m., LVN A said she was the nurse who released Resident #1. She said she did not call a report to the homeless shelter, do medication teaching, have a doctor's order to discharge, or do a discharge summary for Resident #1. She said she was under the 675879 Page 12 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0661 Level of Harm - Minimal harm or potential for actual harm impression the shelter was aware he was coming. She said she did not think about teaching him about his medications or doing a discharge summary. She said she was unsure if she had notified the doctor related to Resident #1's discharge. LVN A said she knew she was supposed to educate the resident about his medication and notify the doctor of his discharge but she did not. LVN A said she could see how all these things needed to be done for the continuation of his care. Residents Affected - Some Record review of Resident #2's face sheet, dated 03/20/24, indicated Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included bipolar (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), stroke, and high blood pressure. Record review of Resident #2's admission MDS assessment, dated 02/05/24, indicated Resident #2 usually understood and usually understood by others. Resident #2's MDS indicated he was cognitively intact. Resident #2 was independent with his ADLs. Record review of Resident #2's comprehensive care plan, dated 4/4/22, indicated Resident #2 had impaired cognitive function, dementia, and impaired thought process related to intracranial pressure (A brain injury or another medical condition can cause growing pressure inside your skull). Record review of Resident #2's progress note, dated 02/09/24, charted by RN M, indicated Resident #2 was discharged to {X) home via our facility transportation. all belongings and medication were handed over by the facility driver. Alert and oriented x4 blood pressure 158/90, pulse 87, heart rate 18, oxygen level 99%, temperature 97. 7, and pain 0/10. Record review of Resident #2's EHR reflected there was no discharge summary on 02/09/24. Record review of Resident #2's physician's orders reflected there was no discharge order on 02/09/24. Record review of Resident 3's face sheet, dated 03/20/24, indicated Resident #3 was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #3 had diagnoses which included diabetes, dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), and Chronic obstructive pulmonary disease, or COPD, (refers to a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #3's admission MDS assessment, dated 01/27/24, indicated Resident #3 understood and understood by others. Resident #1's BIMs score was 15, which indicated he was cognitively intact. Resident #3 required assistance with bed mobility, transfer, and toileting and was independent with eating. Record review of Resident #3's comprehensive care plan, dated 4/4/22, indicated Resident #3 had a self-care performance deficit related to Amputation cultural and religious requests of the left leg below the knee, and limited mobility. Record review of Resident #3's progress note, dated 02/02/24, charted by RN M revealed, Resident #3 was discharged home via family transportation with all belongings and medication handed over to the family member. The physician and DON were notified. 675879 Page 13 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0661 Record review of Resident #3's EHR reflected there was no discharge summary on 02/02/24. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's physician's orders reflected there was no discharge order 02/02/24. Residents Affected - Some During an interview on 3/20/24 at 2:30 p.m., RN M said she discharged Resident #2 and Resident #3 but did not do the discharge summary. She said she was not aware she needed to do a discharge summary. She said she just charted in the chart what she did. She said she was aware residents needed a discharge order but did not realize they did not have an order. During an interview on 03/20/24 at 5:14 p.m., the ADON said the nurses were responsible for starting the discharge summary and she was supposed to follow up on the summaries. She said she was aware some of the summaries were not done when she was reviewing some of the previous discharge summaries yesterday (03/19/24). She said she gave an in-service to staff on 03/19/24 about discharges. She said discharge orders should always be written. She said medication reconciliation and discharge summaries were important for families as well as other facilities for continuity of care post-discharge. During an interview on 03/20/24 at 5:24 p.m., the AIT Administrator said the nurses were responsible for writing discharge orders, medication reconciliation, and starting the discharge summary. She said nurse management was to follow up. She said she did not know all the information a discharge summary included but knew it was important to have because it was a way to communicate care to the families or other facilities. Record review of in-service given on discharge summaries given by the ADON on 03/19/24, revealed, When a resident was to be discharged only the physician, NP, and Physician Assistant can give orders for discharge. Staff should not take orders from anyone else. When a discharge was being worked the nurses should follow up with the physician and document, write the discharge order, and start the discharge summary. Record review of the facility's policy titled, Discharge Summary and Plan, revised October 2022, indicated, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge . 1. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. current diagnosis; b. medical history (including any history of mental disorders and intellectual disabilities); c. course of illness. treatment and/or therapy since entering the facility; d. current laboratory. radiology, consultation, and diagnostic test results; e. physical and mental functional status; f. ability to perform activities of daily living including (1) bathing. dressing and grooming. transferring and ambulating, toilet use, eating. and using speech, language. and other communication systems ; 2. As part of the discharge summary. the nurse reconciles all pre-discharge medication with the resident's pos1-discharge medications. The medication reconciliation is documented. 3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside; b. arrangements that have been made for follow-up care and services; c. a description of the resident's stated discharge goals; d. the degree of caregiver/support person availability, capacity and capability to perform required care; c. how the IDT will support the resident or representative in the transition to post-discharge care; f. what factors may make 675879 Page 14 of 15 675879 03/20/2024 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the rcsiden1 vulnerable to preventable readmission; and g. how those factors will be addressed . 6. The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan . A member of the IDT reviews the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place . 12. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. 675879 Page 15 of 15