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 (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: 676304 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 676304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekside Village 914 N Brazosport Blvd Richwood, TX 77531 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)