Health inspection·July 6, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's SW Progress Note revealed no evidence of documentation to address reason the resident was being discharged , nor the needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. Review of Resident #1's closed medical records reflected no evidence the State Ombudsman was notified by phone or in writing of resident's discharge. Further review of Resident #1's closed records reflected no referral to a higher level of medical or psychiatric care due to resident's dangerous and acute behaviors and subsequent immediate discharge. During an interview on 07/05/2023 at 3:13 PM, the DON stated she had been made aware of Resident #1 the morning of 07/05/2023 but did not work at the facility during the time of the incident. She stated she was told Resident #1 had been sent for a referral to assess his psychological needs which afterward was transferred to a VA home. The DON stated she was unable to give any further information on the incident. During an interview on 07/05/2023 at 3:25 PM, the SW stated the RR was helping them look for alternate placement. She stated there were no letters sent to the Ombudsman and did not feel the need to have the Ombudsman involved. She felt the discharge was facility initiated but stated since the family had already known of the discharge did not feel the Ombudsman needed to be notified. During an interview on 07/05.2023 at 3:53 PM, the RR stated it was the facility that suggested to her that Resident #1 needed to go somewhere else if possible. She stated she never spoke to the Ombudsman nor made aware she was available. During an interview on 07/05/2023 at 4:00 PM, The Interim ADMN stated the rules were different with VA residents and stated it was his understanding when residents were sent to a VA facility, there would be no need for the DC paperwork to be sent to the Ombudsman. During an interview on 07/06/2023 at 11:37 AM, the Ombudsman stated she did not have notifications concerning Resident #1's discharge. She stated this made her nervous that residents may have slipped through the cracks. She stated the last email received from ADMN was 01/2023, before the discharge of Resident #1. The Ombudsman stated anyone leaving facility should be on the monthly report so she could follow up. She stated even VA Residents were considered the same as any other residents and she should have been contacted about Resident #1. She also stated with any (Facility Related, or Resident Related) discharges, she should be notified in the monthly report as to their transfer so she can follow up with the resident and not slip through the cracks. During an interview on 07/06/2023 at 11:51 AM the previous ADMN stated he had spoken to RR telling her his concerns of Resident #1's behaviors. He stated typically there was an email they send to the Ombudsman on a monthly basis. He stated that should have been done per MR and felt it had. The previous ADMN stated he did not feel there was a negative impact for Resident #1 as the RR was involved and knew about the transfer. He stated the facility always involved the Ombudsman with discharges and with Resident #1 did not feel there was a failure. His expectations for discharge letters to go to the Ombudsman so she could follow up with the residents needs in being placed where needed. During interview on 07/06/2023 at 12:34 PM, MR stated that she was unaware of any letters that were sent to the ombudsman for resident any discharges. She also stated she was not sure if anyone in the facility sends any discharge letters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676046 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676046 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Nursing & Rehabilitation 200 County Rd 616 Brownwood, TX 76802 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 During interview on 07/06/2023 at 1:32 PM, the Interim ADMN, SW and DON stated there were no further documents to provide before the exit conference. Level of Harm - Minimal harm or potential for actual harm A record review of the Facility's Policy titled Discharge or Transfer to another Facility not dated, revealed: Residents Affected - Few Facility Initiated Discharge . .A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . .C. These safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident . .Notification of Discharges For facility-initiated transfer or discharge of a resident the facility will notify the resident and the residents representative(s) of the transfer or discharge and the reasons for the move in writing and in language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676046 If continuation sheet Page 3 of 3