Health inspection·October 25, 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, record review, and interview, the facility failed to follow written policies on permitting residents to return to the facility after they were hospitalized or placed on therapeutic leave for 1(CR #1) of 11 residents reviewed for admission, transfer, and discharge. The facility failed to readmit CR #1 after he was hospitalized . This failure could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health. Findings include: Record review of CR #1's face sheet dated 10/25/23 revealed he was [AGE] year-old male admitted to the facility on [DATE] . His diagnoses included, Heart disease, essential hypertension (High blood pressure), Dementia, unspecified severity with other behavior, heart disease, chronic obstructive pulmonary disease, alcohol abuse, insomnia (difficulty falling asleep), legal blindness, hypothyroidism (thyroid disease), vitamin d deficiency, glaucoma, respiratory disorders, and major depression Record review of CR #1's Quarterly MDS assessment dated [DATE] indicated his BIMS score was coded as severely impaired. Record review of his PASRR assessment indicated he was positive for mental illness. Record review of CR #1's nurse note dated 3/14/2023 12:08 read in part : Patient transferred to local behavioral hospital. 3/14/2023 10:10 Nursing progress note: pt initiated physical aggression and struck another resident on the face and was unprovoked. resident taken to room again and continues q 15 min checks. 3/14/2023 08:10 Nursing progress note: pt initiated physical aggression and struck 3 employees. pt isolated in assigned room and placed on q15min checks. Record review of CR #1's clinical records revealed no evidence of discharge letter that was provided to CR #1. During an interview on 10/24/23 at 1:40 PM, Hospital staff said CR #1 was admitted to the hospital on [DATE] due to behavior. She said on 03/24/23, CR #1 was cleared for discharged . She said several Page 1 of 2 676304 676304 10/25/2023 Creekside Village 914 N Brazosport Blvd Richwood, TX 77531

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attempts were made by the hospital, to discharge CR# 1 back, but the facility refused to accept CR #1 back. In an interview with the Social Service Director on 10/25/23 at 3:30 PM, she said CR #1 had behavior problems and was attacking staff and residents. She said the former administrator said not take the resident back because the facility could not meet the needs of CR #1. In an interview with the Administrator and DON on 10/25/23 at 5:30 PM, the Administrator said the DON and herself were new to the facility. The DON said she started September 25th . The Administrator said most of the staff at the facility are new. The ADON just started about a week ago. The Administrator said normally the facility would accept residents sent out for treatment back and re assess the resident to see what can be done and if unmanageable the facility would assist the resident in locating a place that can meet the needs of the resident. Record review of facility's policy dated 2001 Revised December 2016 did not address emergency discharge and permitting residents to return to the facility after being sent out to hospital for evaluation. 676304 Page 2 of 2