Health inspection·October 20, 2023

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to permit residents to return to the facility after they are hospitalized , for 1 (Resident 6) of 3 residents reviewed for fair hearings. The facility failed permit Resident 6 to return to the facility after hospitalization. This failure could place residents, who transfer to hospital, at risk of being denied readmission to the facility and could result in a decreased quality of life and resident's rights violations. Findings included: Record review of Resident 6's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and discharged to a behavioral hospital on 3/14/23. Resident 6's diagnosis included: Alzheimer's disease (neurodegenerative disease that usually starts slowly and progressively worsens, and is the cause of 60-70% of cases of dementia), essential hypertension (high blood pressure), diabetes mellitus (endocrine diseases characterized by sustained high blood sugar levels), major depressive disorder (mental disorder characterized by low self-esteem and loss of interest or pleasure in normally enjoyable activities), chronic kidney disease (loss of kidney function, leg swelling, feeling tired, confusion). Record review of Resident 6's Comprehensive MDS assessment, dated 3/14/23, revealed a BIMs score of 9 out of 15, which indicated moderately cognitively impaired. Resident 6 required limited assistance with dressing, eating and hygiene. Resident required 1 staff with limited assistance with transferring. Record review of Resident 6's Care Plan dated 12/20/22 revealed the following: Aggressive behaviors, Resident 6 accused of slapping and pushing roommate, no date. 2/20/23 Resident accused of stealing item from another resident and then slapping resident on back. 2/23/23 Resident 6 accuses resident of stealing rosary. 2/27/23 transferred to behavioral hospital, returned 3/7/23, no medication adjustments noted. Interventions, if resident has physical behaviors towards another resident, immediately intervene to protect the residents, call for assistance. Monitor/document/report. Place resident on 1;1 until she deescalates and is no longer agitated. Record review of facility's Admission, Transfer, Discharge log for the months of April 2023 through Page 1 of 4 676148 676148 10/20/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few October 20, 2023, revealed Resident 6 was discharged to behavioral hospital on 3/14/23 and had not been readmitted to facility. Observation of facility on 10/19/23 starting at 9:00am, revealed Resident 6 was not the facility. In an interview on 10/19/23 10:12am, DON stated she started working at facility on 10/11/23 and did not know Resident 6 or knew anything about discharge or appeal. DON could not find any records on incident. In an interview on 10/19/23 1:23pm, Area Director of Operations stated she has only been with company for a few months. ADO did not know or have any information about Resident 6's discharge or appeal ruling. In an Interview on 10/19/23 2:34pm, with Ombudsman, she stated the facility did not give Resident 6 a proper notice of facility-initiated discharge and refused to readmit Resident 6 when she was ready to be discharged from behavioral hospital on 3/30/23. Ombudsman stated that Resident 6's guardian was notified by the behavioral hospital that the facility refused to readmit resident. Resident 6's guardian found a facility that would admit Resident 6 on 4/3/23. Ombudsman stated she did not receive any copy of notification or reason from the facility about discharge or why facility refused to readmit Resident 6. Ombudsman stated that guardian informed her he was going to appeal facility's discharge. In an interview on 10/20/23 at 11:34am, Administrator just started working at facility 10/19/23. Administrator stated she knew nothing about Resident 6, the discharge or appeal and could find no records of incident. Record review of Appeal ID #3656231 revealed that on 3/30/23 the nursing facility issued a notice of discharge to Resident 6's Authorized Representative (guardian). Guardian disagreed with the discharge and filed an appeal on 3/31/23. Hearing was schedule for 4/19/23. Resident 6 was not residing in nursing facility while pending the outcome of the appeal. A fair hearing was conducted on 4/19/23. Hearing was ruled in favor of Resident 6 and facility would have 10 days from ruling to readmit. Record review of Resident 6's Appeal Order with hearing date of 4/19/23 and signed by Lead Hearing Officer on 4/25/23 read in part: The undersigned designee of the Executive Commissioner, having received and considered the evidence submitted in this matter, is of the opinion that the preponderance of the evidence establishes that the action on appeal was not in accordance with applicable law and policy. Therefore, that action is REVERSED. In accordance with the findings in this decision, the nursing facility, [facility name] shall rescind the discharge notice of March 30, 2023. [Facility name] must report compliance with this order within 10 days from the date of this decision by (Action Taken on Hearing Decision) to the Hearings Officer at: appealsinfo@hhsc.state.tx.us. An interview on 10/24/23 at 10:12am, guardian stated that she and Resident 6 never heard from facility about being readmitted and the guardian stated that Resident 6 would have declined to readmit to 676148 Page 2 of 4 676148 10/20/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0626 facility and elected to stay where she was currently residing. Level of Harm - Minimal harm or potential for actual harm In an email on 10/24/23 at 10:32am the Certified Hearings Officer stated she never received Form H4807 from facility. Residents Affected - Few On 10/20/23 Facility did not provide Policy and Procedure for Transfers and Discharges when requested by surveyor. Facility did provide policy on Nursing Facility Residents' Rights dated November 2021, from the Ombudsman office. Nursing Facility Residents' Rights, page 3 'Transfers and Discharges' Transfers and Discharges You have the right to: . o Not be discharged from the facility, except in accordance with nursing facility regulations. o Receive a 30-day written notice sent to you, your legally authorized representative or a family member. o Appeal the discharge within 90 days of receiving notice in a Medicaid facility. o Be readmitted to the facility as provided by nursing facility regulations. 676148 Page 3 of 4 676148 10/20/2023 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 6 out of 10 (Resident #4, 8, 9, 10, 11 and 12) rooms reviewed for environment. The facility window blinds in Resident's 4, 8, 9, 10, 11 and 12 rooms were damaged. This failure could place residents at risk for diminished quality of life due to the lack of a well- kept environment. Findings included: Observation on 10/19/23 9:43am revealed that window blinds were damaged, white 2-inch vinyl blades were broken in resident's 4, 8, 9, 10, 11 and 12 rooms. In an Interview on 10/19/23 at 1:23pm, Maintenance Director stated he has only worked at facility for 2 months and was aware of the damaged blinds in resident rooms. Maintenance Director stated that the blinds had not been replaced or repaired because the facility was going to be remodeled. Maintenance Director did not know when the remodel was going to take place. Maintenance Director stated it was his department that was responsible for maintaining the building and equipment in a safe and operable manner at all times. Record Review of Maintenance repair log for August 2023 through October 19, 2023, revealed no repair request was found for the damaged blinds in resident's 4, 8, 9, 10, 11 and 12 rooms. In an Interview on 10/20/23 10:12am, the ADON stated she started working at facility on 10/11/23 and had noticed that the blinds in resident's 4, 8, 9, 10, 11 and 12 rooms were damaged. ADON stated she did not know why blinds had not been replaced or repaired but, had heard that the facility was going to be remodeled. ADON did not know when the remodel was to begin. In an Interview on 10/20/23 10:18am, the DON stated she started working at facility on 10/11/23 and had notice that some blinds in resident room had broken blades. DON did not know why blinds were not replaced or repaired. DON stated it was her understanding that the facility was going to be remodeled but did not know when remodel was going to start. In an Interview on 10/20/23 1:34pm, the Administrator stated she just started working at facility on 10/19/23. Administrator did not know about broken blinds in resident's 4, 8, 9, 10, 11 and 12 rooms. Administrator stated she was told by Interim Administrator that facility was being remodeled but did not know when remodel would begin. 676148 Page 4 of 4