Health inspection·July 7, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 of 5 residents (Resident #1) reviewed for transfer/discharge. The facility did not allow Resident #1 to return to the facility after evaluation and treatment at a Psych Hospital due to the resident potentially still having aggressive and physical behaviors towards others. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health. Findings included: Record review of Resident #1's face sheet, dated 6/24/25, revealed that Resident #1 was a [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease with early onset (a progressive neurodegenerative disorder that primarily affects the brain, causing a gradual decline in cognitive function, including memory and thinking skills), muscle weakness, urinary tract infection, dementia in other diseases classified elsewhere (a general term for a decline in mental ability that significantly impacts daily life, encompassing various conditions like Alzheimer's disease and vascular dementia), moderate with agitation, schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms, like hallucinations and delusion, and mood disorder symptoms, such as depression or mania), depressive type, anxiety disorder, neuralgia and neuritis (pain caused by damaged or irritated nerves and/or inflammation of nerves), folate and thiamine deficiencies (not enough folic acid and vitamin B1), depression, chronic pain, hypertensive heart disease without heart failure, reflux, benign prostatic hyperplasia with lower urinary tract symptoms (prostate gland enlargement that can cause urination difficulty), shortness of breath, restlessness and agitation and hyperlipidemia (high levels of fat particles (lipids) in the blood. Record review of Resident #1's MDS, dated [DATE], revealed that Resident #1 had a BIMs score of 3, which indicates the Resident #1 had severe cognitive impairment. Resident #1 had a functionality of limited assistance needed with the exception to shower/bathing and dressing, which required assistance by one staff. Resident #1 wandered. Record review of Resident #1's care plan, dated 2/14/25, revealed the following:-Care Plan Focus: Resident #1 requires antidepressant medication - date initiated 2/14/25 Care Plan Goal: Resident #1 will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date initiated 2/14/25, target date 5/15/25. Care Plan Interventions/Tasks: -Educate the resident/family caregivers about risk, benefits and the side effects and/or toxic symptoms of antidepressant drugs being given.-Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations.-Monitor/document/report to MD prn ongoing signs and symptoms of depression, unaltered antidepressant medications: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, Page 1 of 6 675945 675945 07/07/2025 Wellington Care Center 1506 Childress St Wellington, TX 79095

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fatigue, lethargy does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. All initiated 2/24/25-Care Plan Focus: Resident #1 uses antianxiety medications date initiated 2/14/25 Care Plan Goal: Resident #1 will be free from discomfort or adverse reactions related to antianxiety therapy through the review date. Date initiated 2/14/25, target date 5/15/25. Care Plan Interventions/Tasks:-Educate the resident/family/caregiver about risks, benefits and he side effects and/or toxic symptoms of antianxiety drugs being given. -Give antianxiety medications ordered by physician. Monitor/documented side effects and effectiveness: antianxiety side effects: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Paradoxical side effects: mania Hostility and rage, aggressive or impulsive behavior, hallucinations.-Monitor/record occurrence of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others document pre facility protocol.-Resident #1 is taking antianxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety. -If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.-Monitor for fatigue and weight loss.-Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. All initiated 2/14/25-Care Plan Focus: Resident #1 is at risk for elopement. Initiated 2/14/25 Care Plan Goal: Resident #1 will remain safe within facility unless accompanied by staff or other authorized person through review date. Initiated 2/14/25, target date 5/15/25 Care Plan Interventions/Tasks:-Assess/record/report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home or hospital.-Supervise closely and make regular compliance rounds whenever resident is in room.-Determine the reason the resident is attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate.-Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxed.-Distract resident from elopement attempts by offering pleasant diversions - structured activities, food, conversation, television, books.-If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. All initiated 2/14/25-Care Plan Focus: Resident #1 resides in the SecureCare Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Initiated 2/14/25 Care Plan Goal: Resident #1 will not have feelings of isolation and will feel safe and secure in the care received while on the SecureCare Unit. Care Plan Interventions/Tasks:-Admit to SecureCare unit per MD orders-Allow resident to perform ADLs to their highest ability, offer assistance as needed.-Assist and monitor resident for off unit activities if able-Engage resident in group activities and provide them with individualized, meaningful projects that they will accomplish throughout the day.-Involve resident in daily activities designed for SecureCare Unit.-Monitor for signs and symptoms of depression, withdrawal from usual activities.-Notify MD of any changes.-Psych services per MD ordersAll initiated 2/14/25-Care Plan Focus: The resident has a behavior problem related to urinating on the floor. Care Plan Goal: The resident will use his commode when urinating by the review date. Initiated 2/14/25, target date: 5/15/25 Care Plan Interventions/Tasks:-Administer medications as ordered. Monitor for side effects and 675945 Page 2 of 6 675945 07/07/2025 Wellington Care Center 1506 Childress St Wellington, TX 79095

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few effectiveness.-Anticipate and meet his needs.-Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by-If reasonable, discuss the resident's behavior. Explain/reinforce why urinating on the floor is inappropriate and/or unacceptable to others.-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.-Praise any indication of resident's progress/improvement in behavior.All initiated 2/14/25-Care Plan Focus: The resident requires antipsychotic medications Care Plan Goal: The resident will reduce the use of psychoactive medication through the review date. Care Plan Treatment/Tasks:-Administer medications as ordered. Monitor/document for side effects and effectiveness.-Consult with pharmacy, MD to consider dosage reduction when clinically appropriate.- Educate the resident/family/caregiver about risks, benefits, and the side effects.-Monitor/record occurrence of behavior symptoms, to include pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol.-Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia (severe involuntary movements), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Record review of Resident #1's progress notes revealed the following: 3/11/25 at 5:10 a.m. - Resident did not sleep last night. Wandering up and down the hall, taking the cushions off the chairs in the TV room, going in and out of resident's rooms. Resident was given Lorazepam 0.5 mg po and Haldol as well with no positive results. 3/11/25 at 10:18 p.m. - Resident has been urinating on the floor in resident's room, resident redirected with negative results. 3/12/25 at 5:43 a.m. - Resident refused peri-care; resident has urinated on himself. CNA attempted several times, resident becomes agitated. 3/20/25 at 5:23 a.m. - Resident urinating on floor and had BM on floor in the dining room, resident redirected stated understanding. 4/20/25 at 9:08 p.m. Resident tried to go into other resident's room, redirected to his room. 4/20/25 at 9:53 p.m. - Resident has been combative with staff and residents. Resident made close fist coming in contact with staff left side of face. Staff face read and swollen and causing pain to staff. Resident redirected several times with no success. Resident continues to ambulate up and down the hall. Attempted to administer prn medicine, resident refused, spit medicine out. Administration has been notified. This LVN was able to redirect resident to room. Resident is now lying in bed. Will continue to monitor. 4/21/25 at 8:15 a.m. - Haloperidol Oral tablet 5 mg, give one tablet by mouth every 6 hours as needed for anxiety for 14 days 4/21/25 at 11:21 a.m. Resident with aggressive behaviors yesterday, referral made to Psych hospital #1. Psych hospital #1 accepted at this time. 4/21/24 at 4:29 p.m. - Resident is awaiting to be transferred to Psych hospital #1. No noted mental or physical distress. 5/21/25 at 11:35 a.m. - RN from Psych hospital #1 call and gave report on this resident. Resident has not had any aggression or agitation within the last few days, last aggressive behavior on 5/13/25 when resident pushed roommate and caused him to fall. Has two new orders, paperwork sent with resident. No skin issues noted. Resident on the way with Psych hospital staff. 5/21/25 at 4:53 p.m. - Resident being verbally aggressive with staff, refusing to leave other resident's rooms. Wanting to leave now. Notified doctor and new orders received. Notified Psych hospital #1 and will send a new referral at this time. 5/21/25 at 6:09 p.m. - Psych hospital #2 has accepted resident at this time. 5/23/25 at 2:25 p.m. - Resident will return from Psych hospital #2 today. He will admit to Psych hospital #1 tomorrow as they have accepted him. Family notified and they will transport resident in the am to Psych hospital #1. 5/24/25 at 675945 Page 3 of 6 675945 07/07/2025 Wellington Care Center 1506 Childress St Wellington, TX 79095

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1:54 a.m. - readmission Note: accompanied by staff. Vitals normal. Assessment completed. 5/24/25 at 9:26 a.m. - family here at this time to transport resident to Psych hospital #1. 6/20/25 at 2:51 p.m. - SW was contacted by DON to reach out to resident's brother to give an update on resident. SW contacted family and explained the resident had been denied at several facilities. Resident's brother reported that he had a contact at another facility that he had received from a family member. SW contacted NF #1 to send referral for resident - denied. SW also reached back out to NF #2 and #3 to check on referral. Resident has been denied at several facilities including NF #4 and #5. SW explained to family that referrals had been sent to several facilities without acceptance. Resident is still at Psych hospital #1. SW called NF #3 but was unable to speak to DON/Marketer. SW explained that she would attempt to reach back out to facility on Monday. Family voiced understanding. SW and family reviewed a list of secure care facilities. SW attempted to reach out to NF #6 and attempted to fax a referral to them. SW explained to family that she would again reach out to the SW at the facility to confirm fax number. SW explained to family that the 30-day letter stood. Resident's family were concerned about his belongings. SW explained that resident's belongings would not be thrown out. SW educated family several times during conversation about 30-day notice that they could reach out to the Administrator on Monday. Family member stated, Maybe we should just call State and let them work this out. SW make several phone calls to family and back and forth with family between 2:45 and 4:00 p.m. SW also notified DON and Administrator about phone calls and conversation. 6/23/25 at 9:44 a.m. - Facility SW contacted NF #3's DON about referral for resident. He asked SW to email it to him and stated that she would follow up with him. SW sent referral to NF #7 and NF #8. SW spoke with SW at NF #1, and she asked for updated records for resident from Psych hospital #1. SW emailed case manager, and she reported that she reported that she would send records to NF #1. SW followed up with NF #2 on Friday, June 20th and they reported that resident had been denied due to behaviors. SW also sent referrals to NF #5, and he was denied due to behaviors. SW attempted to send referral to NF #6 again. SW called to verify tax number, and they gave SW another number, Facility SW attempted to follow up with SW. 6/24/25 at 9:36 a.m. - SW contacted NF #1 again this morning about referral. NF #1 reported they have not seen any records from Psych hospital #1 yet. SW contacted Psych hospital #1 on Friday and again yesterday to send records to NF #1 per request of family and facility. NF #1 stated today that unless he was doing much better that she did not feel they would accept him because they would not be able to meet his needs. SW again attempted to call Psych hospital #1 case manager to follow up on records. SW left a voice mail for return call. SW attempted to follow up with NF #3 DON again this morning. He stated that he would contact SW back after morning meeting. SW has sent referral via email to Administrator and DON. He reported that he would follow up with SW after morning stand up meeting about possible fax number. SW attempted to call NF #7 and NF #8 this morning about referrals. SW left a message for DON and NF #7 and was unable to get ahold of anyone at NF #8. 6/24/25 at 9:58 a.m. - SW called NF #6 to follow up on referral. SW attempted to call X2. SW was on hold, and they hung up. SW attempted to call back and was on hold for 20 minutes with no answer. Resident was denied by NF #4 because they were afraid of him getting hurt because he wanders. He was also denied by NF #9 per DON. SW updated administrator and DON. 7/2/25 at 10:24 a.m. - SW sent a referral to NF #10. SW called and followed up with NF #7 and he was denied. SW also called to follow up with NF #8 and left a voicemail for return call about decision on placement. SW spoke with NF #1 and was informed that she cannot take him at this time. Referral will be sent to NF #11. She reported that she did not feel that he would be accepted at either place at this time. SW attempted to follow up with NF #6. Left a message for them to call back. SW will call again and follow up later this morning. 675945 Page 4 of 6 675945 07/07/2025 Wellington Care Center 1506 Childress St Wellington, TX 79095

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7/2/25 at 11:09 a.m. - SW called again to follow up with NF #6. Referral sent again per request of NF #10. SW waiting on call back from NF #6. 7/2/25 at 11:49 a.m. - NF #6 called and spoke to SW about referral. She reported that they were reviewing the referral for them. They would be reaching out to NP and to Psych hospital #1 to determine if they would be able to take him. She reported that she would contact SW by the end of the day. She also confirmed again that he had been denied at NF #9. 7/2/25 at 12:11 p.m. - SW spoke to NF #3 again to follow up on referral. Resnet again to the DON per request of facility. 7/2/25 at 2:05 p.m. - SW was notified by NF #10 that resident was denied for placement. 7/7/25 at 10:31 a.m. - NF #6 called and requested 90 days of nursing notes. Sent this morning. During an interview on 7/7/25 at 10:20 a.m., the Administrator, stated the Ombudsman got involved with Resident #1 and appealed his 30-day discharge and the facility lost the appeal. The Administrator stated even though the facility lost the appeal, she was not going to take Resident #1 back because she needed to protect all the residents and staff from Resident #1's aggressive behaviors because she was not going to let him hurt anyone in the facility. The Administrator stated if she took Resident #1 back, that would put everybody at risk of harm. The Administrator stated Resident #1 was in a Psych hospital #1 and that hospital had never looked for a place to send Resident #1 upon discharge and they knew she was not taking Resident #1 back in the building due to his behaviors. [NAME] stated the Ombudsman even said in the appeal meeting that the facility could not meet Resident #1's needs as he needed a memory care unit, and the appeal person still upheld the appeal. The Administrator stated she was not sure what was going to happen, but she was not going to take Resident #1 back at the risk of someone getting hurt. An attempt on 7/7/25 at 10:15 a.m. to contact the Ombudsman was unsuccessful. A detailed message was left along with a contact number. Record review of a Complaint intake #1020445, received 7/1/25, documented the following:It was unknown when Resident #1 was admitted to the facility. The complaint stated Resident #1 has been at the facility for at least seven months. On 5/21/25, Resident #1 received a 30-day discharge notice. The resident was supposed to be discharged on 6/20/25. However, Resident #1 was transferred to a behavior hospital, and she was not certain of the date. On 6/23/25, the complainant was contacted by the Administrator, stated that they were going to proceed to discharge Resident #1. The complainant filed a discharge appeal on Resident #1's behalf. On 7/1/25, the behavior hospital was ready to discharge Resident #1, however, the nursing facility was refusing to take him back. The complainant spoke to the Administrator, who confirmed the facility did not intend to take Resident #1 back. The Administrator also confirmed receipt of the request for a discharge hearing. The Administrator understands that the facility is supposed to have him back in the facility until the hearing and she is still refusing. The complainant is currently writing an email to see if the appeal process can be expedited. During an interview on 7/7/25 at 11:45 a.m., LVN A stated she had taken care of Resident #1 on many occasions. LVN A stated when Resident #1 showed his attitude, he was very scary. LVN A stated Resident #1 never hit her, but he had hit other staff members before. During an interview on 7/7/25 at 11:50 a.m., LVN B stated she was working when Resident #1 came back from the behavior hospital, his behaviors were way different. LVN B stated Resident #1 thought everyone was in his house, and he was trying to throw everyone out. LVN B stated Resident #1 was sent out again because a resident was in his room, and he got aggressive. LVN B stated Resident #1 was not in the facility 30 minutes and he was a whole different person, he was way worse. LVN B stated Resident #1 would lunge at staff so she would keep a distance from him as she was trained to do. During a telephone interview on 7/7/25 at 12:20 p.m., the Facility SW stated she was not present for any of Resident #1's behaviors, she just knew what she was told from staff. The SW stated she has tried every place his family wanted him to go, and several other places 675945 Page 5 of 6 675945 07/07/2025 Wellington Care Center 1506 Childress St Wellington, TX 79095

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she has had no luck finding a place. The SW stated she was still trying to find Resident #1 placement, but the behavioral hospital was not helping with placement at all. During a follow-up interview on 7/7/25 at 12:35 p.m., the Administrator provided a documented timeline of the events for a clearer picture of the events leading up to Resident #1's discharge that reflected the following: Resident #1 was admitted on [DATE]. They were told by the family that his only behavior was urinating on the floor. When he got here, we were told by hospice that he would make false accusations toward his family and would become aggressive. From the beginning, Resident #1 was hard to redirect and would go into other resident rooms, would pull out his dresser drawers and pull everything off the walls. On 4/20/25, he punched a CNA in the face when attempting to redirect. He was referred to Psych hospital #1 and transferred out on 4/21/25. Documentation from Psych hospital #1 noted that behaviors had improved, and he returned on 5/21/25. Resident #1 was more aggressive upon return than when he left. Resident #1 was in the facility for 4 hours when he was referred to Psych hospital #2 because Psych hospital #1 refused to take him back. Resident #1 was issued a 30-day notice at that time. Ombudsman, Psych hospital #2 and family received a copy of the notice. Resident #1 returned to the facility from Psych hospital #1, who could not get our judge to sign to hold him, on 5/23/25, Resident #1's family picked him up and drove him to Psych hospital #2 on 5/24/25. During the overnight stay at the facility, Resident #1 was provided one on one care to protect the safety of the other residents. On the morning of 7/1/25, the Administrator revealed a call from Psych hospital #1's case manager asking if the facility was going to take Resident #1 back because she knew there was a 30-day discharge from the facility, which was 6/20/25 but Resident #1's family member had informed her that the facility had to take him back, per the Ombudsman. The case manager was informed they were not taking him back but had been trying to help them place him. The Administrator then received a call from the Ombudsman saying we had to take him back and the Administrator told her they could not take him back for the safety of the other residents. At 5pm, the Administrator received notice of hearing at 2pm the next day. The facility lost the appeal hearing. Record review of the facility provided policy titled Transfer and Discharge, revised 2/12/25, documented the following: Emergency Transfers to Acute Care - Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected. Discharge pending appeal - When a resident chooses to appeal his or her discharge from the facility, the facility will not discharge the resident while the appeal is pending. A facility's determination to not permit a resident to return while an appeal of the resident's discharge is pending must not be based on the resident's condition when originally transferred to the hospital. 675945 Page 6 of 6