Health inspection·April 12, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to have the resident's physician document their discharge and all other necessary information in the medical records. This failure could place residents at risk of not getting the necessary care and services in a new facility to meet their physical and psychological needs. The findings were: Record review of Resident #1's face sheet revealed a [AGE] year-old who was initially admitted to the facility on [DATE] and discharged on 2/28/2024. Resident #1's medical diagnoses included Alzheimer's disease, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder (severe), Depression, schizoaffective disorder (bipolar type), and unspecified dementia (unspecified severity, with other behavioral disturbance). Record review of Resident #1's MDS (Minimum Data Set, a standardized resident assessment tool) dated 02/15/2024 revealed their BIMS score (Brief Interview for Mental Status, which measures for cognitive impairment) was an 8. Record review of Resident #1's care plan dated 02/28/2024 revealed they were care-planned for physical and verbal aggression with a target date of 3/1/24: Focus: I have a diagnosis of Schizophrenia and am at risk for Disturbed Thought Processes, non-compliant with care, physical and verbal aggression. Goals: I will be free from delusions and demonstrate the ability to function without responding to persistent delusional thoughts & aggression . Interventions included monitoring behavior episodes, document behavior and potential causes, and psychiatric/psychogeriatric consult as indicated. Record review of Resident #1's medication administration record (MAR) for February 2024 revealed that they were taking quetiapine fumarate oral tablet 100 mg for schizoaffective disorder (bipolar Page 1 of 5 675996 675996 04/12/2024 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0622 type), Fluoxetine HCL 20mg capsule for depression, and Aripiprazole oral tablet 5mg for dementia. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's wandering risk scale assessment dated [DATE] revealed Resident #1 was residing on the secure unit due to their history of exit-seeking behaviors. Residents Affected - Few Record review of Resident #1's medical records revealed no documentation stating the reasons for the resident's discharge from the facility. Further review found no discharge summary for Resident #1. Interview with Resident #1's representative on 2/12/2024 at 8:50 a.m., they said the facility staff were all nice but that they just could not handle Resident #1's behaviors. They said the hospital Resident #1 was discharged to was trying to look for another facility for them but was unable to do so as of this interview. They said they just wanted Resident #1 to have the right dose of medication so they can be calm. Interview with the facility's Ombudsman on 2/12/2024 at 2:37 p.m., they said that they were notified of Resident #1's transfer to the hospital but did not receive verbal or written notice of Resident #1's discharge from the facility. Interview with the facility's Social Worker (SW) on 4/12/24 at 1:23 p.m., they said Resident #1 was sent to the hospital for a psychiatric evaluation due to his behaviors and then they left. When asked to specify what behaviors meant, the SW said Resident #1 was physically abusive to staff and that the staff are doing okay now. The SW said if Resident #1 came back it would be considered an unsafe placement which is why the resident could not return. They said they attempted to call Resident #1's representative multiple times with an interpreter (due to language barrier) to inform the family of the discharge but the facility was unable to reach them. Interview with the facility''s SW on 4/12/24 at 2:30 p.m., they said they had Resident #1's discharge documentation the previous day but could not locate them now. Interview with the previous DON (Director of Nursing) on 4/12/24 at 1:40 p.m., they stated that Resident #1 was sent to the psychiatric unit of a hospital, who told the facility they would find a new place for the resident. The DON does not know where Resident #1 was transferred to since the hospitals usually never inform the facility of that information. When asked what information gets sent to the hospital upon discharge, the DON stated that discharge paperwork can include medication lists, history and physical if the hospital requests it. Interview with the Regional Administrator (RA) on 4/12/24 at 3:40 p.m., they stated that Resident #1 was physically aggressive with staff and that the resident could not be properly taken care of at the facility. They stated that the hospital told the facility they would take charge of finding a new facility for the resident, so the facility did not need to have any discharge plans for this resident. They stated they also could not send any information to the new facility because Resident #1 was being discharged from the hospital. The facility would not know where Resident #1 was to be discharged . When asked if they had documentation regarding the hospital's statement, the Regional Administrator stated they did not have any records of this conversation. When asked if the facility informed the Ombudsman, the RA stated that the facility is supposed to inform the Ombudsman and that they believed someone at the facility did do that. Record review of the Resident #1's admission Agreement dated 2/8/2024 and signed by the resident 675996 Page 2 of 5 675996 04/12/2024 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few representative, the Statement of Resident Rights include the right to not be discharged from the facility, except as provided in the nursing facility regulations. Record review of the facility's Transfer or Discharge policy statement, undated, stated that When a resident is scheduled for transfer or discharge, the facility will coordinate the transfer or discharge so that appropriate proceudres can be implemented. Further review revealed that a post-discharge plan is to be reviewed with the resident, their responsible party. Nursing services is responsible for actions such as: obtaining orders for discharge or transfer, preparing the medications to be discharged , packing and collecting personal possessions, and informing appropriate departments of the resident's transfer or discharge. 675996 Page 3 of 5 675996 04/12/2024 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman and failed to record the reasons for transfer or discharge in the resident's medical record for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to notify the Ombudsman of Resident #1's discharge status after hospitalization. This failure could place residents at risk of being improperly discharged and not having access to available advocacy services, discharge/transfer options, and the appeal process. The findings were: Record review of Resident #1's face sheet revealed a [AGE] year-old who was initially admitted to the facility on [DATE] and discharged on 2/28/2024. Resident #1's medical diagnoses included Alzheimer's disease, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder (severe), Depression, schizoaffective disorder (bipolar type), and unspecified dementia (unspecified severity, with other behavioral disturbance). Record review of Resident #1's MDS (Minimum Data Set, a standardized resident assessment tool) dated 02/15/2024 revealed their BIMS score (Brief Interview for Mental Status, which measures for cognitive impairment) was an 8. Record review of Resident #1's care plan dated 02/28/2024 revealed they were care-planned for physical and verbal aggression with a target date of 3/1/24: Focus: I have a diagnosis of Schizophrenia and am at risk for Disturbed Thought Processes, non-compliant with care, physical and verbal aggression. Goals: I will be free from delusions and demonstrate the ability to function without responding to persistent delusional thoughts & aggression . Interventions included monitoring behavior episodes, document behavior and potential causes, and psychiatric/psychogeriatric consult as indicated. Record review of Resident #1's medication administration record (MAR) for February 2024 revealed that they were taking quetiapine fumarate oral tablet 100 mg for schizoaffective disorder (bipolar type), Fluoxetine HCL 20mg capsule for depression, and Aripiprazole oral tablet 5mg for dementia. Record review of Resident #1's wandering risk scale assessment dated [DATE] revealed Resident #1 was residing on the secure unit due to their history of exit-seeking behaviors. Record review of Resident #1's medical records revealed no documentation stating the reasons for the resident's discharge from the facility. Interview with Resident #1's representative on 2/12/2024 at 8:50 a.m., they said the facility staff 675996 Page 4 of 5 675996 04/12/2024 Columbus Oaks Healthcare Community 300 North St Columbus, TX 78934

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were all nice but that they just could not handle Resident #1's behaviors. They said the hospital Resident #1 was discharged to was trying to look for another facility for them but was unable to do so as of this interview. They said they just wanted Resident #1 to have the right dose of medication so they can be calm. Interview with the facility's Ombudsman on 2/12/2024 at 2:37 p.m., they said that they were notified of Resident #1's transfer to the hospital but did not receive verbal or written notice of Resident #1's discharge from the facility. Interview with the facility's Social Worker (SW) on 4/12/24 at 1:23 p.m., they said Resident #1 was sent to the hospital for a psychiatric evaluation due to his behaviors and then they left. When asked to specify what behaviors meant, the SW said Resident #1 was physically abusive to staff and that the staff are doing okay now. The SW said if Resident #1 came back it would be considered an unsafe placement which is why the resident could not return. They said they attempted to call Resident #1's representative multiple times with an interpreter (due to language barrier) to inform the family of the discharge but the facility was unable to reach them. Interview with the facility''s SW on 4/12/24 at 2:30 p.m., they said they had Resident #1's discharge documentation the previous day but could not locate them now. Interview with the previous DON (Director of Nursing) on 4/12/24 at 1:40 p.m., they stated that Resident #1 was sent to the psychiatric unit of a hospital, who told the facility they would find a new place for the resident. The DON does not know where Resident #1 was transferred to since the hospitals usually never inform the facility of that information. When asked what information gets sent to the hospital upon discharge, the DON stated that discharge paperwork can include medication lists, history and physical if the hospital requests it. Interview with the Regional Administrator (RA) on 4/12/24 at 3:40 p.m., they stated that Resident #1 was physically aggressive with staff and that the resident could not be properly taken care of at the facility. They stated that the hospital told the facility they would take charge of finding a new facility for the resident, so the facility did not need to have any discharge plans for this resident. They stated they also could not send any information to the new facility because Resident #1 was being discharged from the hospital. The facility would not know where Resident #1 was to be discharged . When asked if they had documentation regarding the hospital's statement, the Regional Administrator stated they did not have any records of this conversation. When asked if the facility informed the Ombudsman, the RA stated that the facility is supposed to inform the Ombudsman and that they believed someone at the facility did do that. Record review of the Resident #1's admission Agreement dated 2/8/2024 and signed by the resident representative, the Statement of Resident Rights include the right to not be discharged from the facility, except as provided in the nursing facility regulations. Record review of the facility's Transfer or Discharge policy statement, undated, stated that When a resident is scheduled for transfer or discharge, the facility will coordinate the transfer or discharge so that appropriate proceudres can be implemented. Further review revealed that a post-discharge plan is to be reviewed with the resident, their responsible party. Nursing services is responsible for actions such as: obtaining orders for discharge or transfer, preparing the medications to be discharged , packing and collecting personal possessions, and informing appropriate departments of the resident's transfer or discharge. 675996 Page 5 of 5