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
interview and record review, the facility failed to follow its written policy on permitting residents to return to
the facility after they were hospitalized for 1 of 1 closed record (Resident #1) reviewed for
admission/transfer/discharge rights.
CR #1 was not allowed to return to the facility after being sent to doctor's office and hospital.
This failure could place residents at risk for not receiving care and services to meet their needs upon
discharge, a disruption of care, and being discharged without alternate placement.
The findings included:
Review of CR #1's closed record's face sheet dated 04/25/23 reflected a [AGE] year-old female admitted to
the facility on [DATE] with diagnoses that included: muscle weakness, difficulty in walking, repeated falls,
anxiety disorder, hypothyroidism (A condition resulting from decreased production of thyroid hormones) and
hypertension. Resident #1 was her own responsible party.
Record review of CR #1's MDS dated [DATE] reflected her BIMs Score was 15 indicating she was mentally
competent.
Record review of CR #1 Hospital discharge paper dated 12/27/22 reflected CR#1 was discharged from
hospital to another facility on 12/27/22.
Record review of Intake ID # 415595 dated 03/31/23 reflected CR #1 was involuntary discharged from
facility.
Record review of facility's provided letter, titled NMNC signed by facility staff on 10/02/22 and unsigned by
resident \responsible party reflected that skilled service would end on 10/03/22.
Record review of nurse's note dated 12/16/2022 3:30PM, read in part: Resident went to the MD
appointment on 6am-2pm shift, on this 2pm-10pm shift, PCT called and said that resident was transported
to the emergency from the doctor appointment .
In an interview with facility staff on 04/25/23 at 3:00PM, she said CR # 1 was issued a discharge notice on
10/20/22 and an appeal was requested on 11/10/22. She said Resident was not accepted back to the
facility since resident was already issued a discharge letter while she was in and out of hospital. She said
Resident #1 was in the window period of being discharged . She said the hospital
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676204
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
676204
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/25/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Cedar Bayou
2000 W Baker Road
Baytown, TX 77521
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 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Staff told her that Resident #1 was discharged to a safe place where her needs could be met. She said CR
#1 would not be re-admitted to the facility due to nonpayment. She said Resident#1's Medicaid application
was denied due to lack of medical necessity.
Record review of Fair Hearing - Medicaid dated 12/20/2022 titled - Nursing Facility Discharge Case
Number: 184427248; Appeal ID: 3614410 read in part- The Hearings Officer instructs the nursing facility to:
o Allow the Appellant to remain in the facility and do not discharge Appellant from the facility.
o Within 10 days from the date of this decision, the nursing facility must report compliance with this order.
o This order does not preclude the nursing facility from processing any future notices of discharge, and the
Appellant or
Appellant's representative retains the right to appeal any future discharge actions by the nursing facility.
During an interview with Hospital Social Worker B on 04/25/22 at 4:00PM, he said the initial facility was
contacted prior to resident's discharge and he was told by the facility staff that the facility would not accept
the resident back. He said he made other arrangements and was able to send CR # 1 to another local
rehab facility for treatment.
During an interview with Facility Administrator and DON on 04/25/22 beginning at 4:30PM the Administrator
said it was the policy of the facility to accept resident's back to the facility. She said all discharges\readmit
always come through another department that handle all admissions. She said the facility normally receive
a letter from the admission team to expect the resident she said she was not at the facility during the time
of Resident #1. The DON said the facility did not receive any notice from the admission team on behalf of
CR #1.
Record review of facility's policy on admission, transfer and discharge rights dated 2001 updated 2005 read
in part-Each resident will be permitted to remain in the facility and not transferred or discharged .
#2 if the resident exercises his or her right to appeal a transfer or discharge notice he\she will not be
transferred or discharged while appeal is pending .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676204
If continuation sheet
Page 2 of 2
