Health inspection·January 12, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not provide, in writing, a bed-hold notice upon transfer at the time of transfer of a resident to a hospital or for therapeutic leave, for 1 of 3 residents (CR#1) reviewed for transfers and discharge. -The facility failed to provide bed-hold notifications to CR#1 when she was transferred to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred. Findings included: Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: spinal stenosis (a narrowing of the spinal canal), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) and hypokalemia (a blood level that is below normal in potassium). CR#1 was transferred to an acute care hospital on [DATE]. Record review of CR#1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. She required extensive assistance from two persons, physical assist with bed mobility, dressing, personal care, and hygiene. Required total dependence with toilet use. CR#1 was frequently incontinent of bladder and bowel. Record review of CR#1's Discharge MDS assessment dated [DATE] revealed the resident's return was anticipated post discharge, and it was an unplanned discharge with no evidence of an acute change in mental status. Record review of CR#1's Care Plan initiated 04/13/2023 and updated on 04/26/2023 revealed the following: Focus- (CR#1) had an ADL self-care performance deficit r/t Spinal Stenosis. Goal: The resident will improve current level of function in ADLs through the review date. Interventions: Bathing/showering: The resident requires extensive assistance by (1) staff with bathing/showering as necessary. Toilet use: The resident is totally dependent on 1 staff for toilet use. Record review of CR#1's Progress Note dated 09/18/23 at 2:46am written by LVN A revealed, Resident Page 1 of 3 676371 676371 01/12/2024 Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459

F 0625 transferred at 0210 in stable condition via [company name] EMS . Level of Harm - Minimal harm or potential for actual harm Record review of CR#1's September 2023 EMR revealed no transfer or discharge plans documented. Record review of CR#1's paper/electronic chart revealed no notification of the facility's bed hold policy. Residents Affected - Few In a telephone interview on 01/12/2024 at 9:14a.m., with the Ombudsman, he said on 8/21/23, had a fair hearing for an improper discharge and on 9/13/23, received notification CR#1 won the hearing. He said CR#1 was sent to the hospital in stable condition. The facility failed to provide a written bed hold policy to CR#1 upon transfer. Attempted telephone interview on 01/12/2024 at 9:34 a.m., with CR#1 was unsuccessful. In an interview on 01/12/2024 at 9:44a.m., the Administrator said the Social Worker was responsible for discharge planning. He said residents that were sent to the hospital for acute care had the right to return to the facility. The Administrator said the bed hold policy was not provided to the residents at admission. The Administrator said the facility's admission packet did not include the bed hold policy. He said it was a form that was given by nursing in the event of a transfer. In an interview on 01/12/2024 at 9:59 a.m., with the Administrator and the DON, the DON said CR#1 was not provided a written bed hold policy upon transfer. CR#1 was transferred sometime in September 2023. The DON said corporate created a bed hold form in the end of December 2023. She said residents that were transferred in January 2024 should have a bed hold form in their electronic medical records. In an interview on 01/12/2024 at 10:38a.m., the Social Worker said that she was responsible for the resident discharge process. She said when a resident was transferred to the hospital, they had the right to return but, she was not aware of the requirement to present the residents with a bed hold policy. In an interview on 01/12/2024 at 11:31a.m., with LVN A, he said he worked full time at this facility. He said CR#1 was transferred to the hospital in stable condition. He said he did not provide CR#1 with bed hold policy. LVN A said, I have heard of the bed hold at other facilities that I have worked at but not at this facility. In a telephone interview on 01/12/2024 at 1:15 p.m., with CR#1's Family Member, she said CR#1 was discharged to the hospital on [DATE]. She said CR#1 was not provided an explanation of the resident's rights to remain at the facility, the bed hold policy, or any discharge planning. Record review of the facility's Bed Hold Notice Upon Transfer policy dated 10/24/22 revealed read in part: . Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Definitions: Bed-Hold means the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 676371 Page 2 of 3 676371 01/12/2024 Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459

F 0625 Reserve Bed Payment refers to payments made by a State to the facility to hold a bed during a resident's temporary absence from a nursing facility. Level of Harm - Minimal harm or potential for actual harm Therapeutic Leave refers to absences for purposes other than required hospitalization. Residents Affected - Few Policy Explanation and Compliance Guidelines: Bed Hold Notice Upon Transfer 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: o The resident requires the services which the facility provides; o The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 2. In the event of an emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan . 676371 Page 3 of 3