Health inspection·July 18, 2023

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 notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for 2 (Resident #5 and #10) of 2 residents reviewed for discharge. The facility failed to notify the Office of the State Long-Term Care Ombudsman for Resident #5. The facility failed to notify the Office of the State Long-Term Care Ombudsman for Resident #10. This failure could place residents at risk of being inappropriately discharged and not receiving the needed services upon discharge. Findings included: Record review of Resident #5's electronic medical record revealed an [AGE] year-old male admitted on [DATE] with the following diagnoses: Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking); senile degeneration of brain (similar to dementia); alcohol abuse with alcohol-induced mood disorder and metabolic encephalopathy (a chemical imbalance in the brain). Resident # 5 was discharged on 04/26/2023 to another facility. Record review of Resident #10's electronic medical record revealed a [AGE] year old male admitted on [DATE] with the following diagnoses: Vascular dementia (impairment of memory caused by an impaired supply of blood to the brain), unspecified severity, with agitation; generalized anxiety disorder; alcohol dependence with alcohol-induced disorder; acute myocardial infarction (heart attack) and unspecified sequelae of cerebral infarction (residual or aftereffects after an acute stroke has ended). Resident #10 was discharged on 07/14/2023 to another facility. In an interview with the ADM on 07/18/2023 at 03:42 PM, the ADM said that residents show a pattern of bad behavior(s) his company expects him to transfer the resident to another facility able to handle those behaviors. The ADM mentioned Resident # 10 as aggressive and did not respond to re-direction or other treatments/interventions. The ADM said relocation was the last resort if other interventions failed. In an interview with the DON on 07/18/2023 at 05:26 PM, the DON said notifications to both resident's families were done but there was no notification sent to the Ombudsman office. The DON did not offer an explanation why the Ombudsman was not notified. Page 1 of 2 676148 676148 07/18/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0623 The facility did not provide a policy on discharges or discharge notifications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676148 Page 2 of 2