Health inspection·December 12, 2024

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 for 1 (Resident #1) of 5residents reviewed for transfer/discharge. The facility failed to provide a notice of discharge to the facility's Ombudsman as soon as practicable when Resident #1 was discharged on 12/11/24 to a locked unit at another facility due to the current facility not being able to meet Resident #1's needs. This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Review of Resident #1's face sheet dated 12/12/2024 reflected the resident was an [AGE] year-old female, with admission date of 12/26/2023 and then discharged to another facility on 12/11/2024. The resident had diagnoses which included but not limited to: Alzheimer's disease (memory loss), anxiety disorder, muscle weakness, and wandering. Review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS of a 7 out of 15 which indicated that the resident had severe cognitive impairment. Review of Resident #1's progress notes dated 12/11/2024 revealed the resident was being transferred on 12/11/24 to another facility. During a phone interview on 12/12/2024 at 8:45 AM, the Ombudsman stated that she did not know about Resident #1's discharge on [DATE] and that she was supposed to be notified at the same time the resident was notified of the transfer/discharge . During an interview on 12/12/2024 at 11:44 AM, the ADM supplied a copy of the transfer/discharge summary for Resident #1 that was signed by the resident. The ADM stated that she notified the Ombudsman of Resident #1's discharge on [DATE]. During an interview on 12/12/24 at 11:57 AM, the DON stated that she was not sure whose responsibility it was to send transfer and discharge notices to the Ombudsman, but it was either herself or the ADM. She stated that if the Ombudsman was not notified of a transfer/discharge, they would not know where the resident was residing. Page 1 of 4 676186 676186 12/12/2024 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/12/24 at 12:03 PM, the ADM stated that it was her or a designee's responsibility to make sure discharge/transfer notices were sent to the Ombudsman and that if it was not sent, the Ombudsman would not be aware of what was going on with the resident . Record Review of Transfer/Discharge Report for Resident #1 revealed it was, dated and signed by Resident #1 on 12/11/24 at 02:27 PM. Review of the facility's policy, provided by the DON, titled Transfer and Discharge, not dated, reflected in part: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. .Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: An immediate transfer or discharge is required by the resident's urgent medical needs. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and the LTC ombudsman as soon as practicable before the transfer or discharge. 676186 Page 2 of 4 676186 12/12/2024 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The Dietary Manager failed to have the appropriate license, certification, or qualifications to function as the Director of Food and Nutrition Services. This failure could place residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: Record Review of a current facility employee roster including hire date, indicated the DM's date of hire was 04/30/2024. During an interview on 12/12/24 at 7:14 AM, the DM stated she had been employed at the facility since April , 2024 but had been the DM since June , 2024. When asked for her certification for DM, she stated she was not certified or enrolled in a class to become certified at this time. The DM stated that she was waiting for corporate to send her an email so she could get enrolled in the class. During an interview on 12/12/24 at 9:00 AM, the ADM stated the DM was not certified but will be taking classes soon, hopefully the beginning of next year. She stated that they do have a RD who the DM consults with, but she was not full time. In an interview on 12/12/24 at 11:55 AM, the DON stated she was responsible for making sure staff were trained appropriately and that a negative outcome for not having a DM that was trained could be weight loss in residents, wrong orders given to residents in regard to purees, mechanical diets, and portion sizes. In an interview on 12/12/24 at 12:03 PM, the ADM stated that all department heads and herself were responsible for making sure that staff were properly trained and that she was not here when the DM was hired for that position. The ADM stated possible negative outcomes for not having a DM that was certified could be possible weight loss and dietary requirements not being met for residents, for example, making sure diabetic residents were not getting sugary desserts. Record Review of the facility policy titled Dietary Services-Staffing, not dated, included in part: Policy: The facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. .3. If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility will designate a person to serve as the director of food and nutrition 676186 Page 3 of 4 676186 12/12/2024 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0801 services who is: Level of Harm - Minimal harm or potential for actual harm i. A certified dietary manager. Residents Affected - Many 676186 Page 4 of 4