Health inspection·February 26, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure before a resident transfers or discharges from the facility the notice of transfer or discharge required under this section was made by the facility at least 30 days before the resident was transferred or discharged for one of 2 residents (Resident #1) reviewed for discharge requirement. 1) The facility failed and refused to readmit Resident #1 from the hospital where she was transferred for evaluation and treatment. 2) The facility did not give Resident #1 or the representative a discharge notice when she was transferred to another facility from the hospital. 3) The facility did not permit Resident #1 to remain in the facility and failed to initiate a 30-day discharge based upon the facility's ability to meet the resident's needs and welfare. 4) There was no documentation from the physician indicating that the resident had specific needs that could not be met in the facility. 5) The facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay that included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. 6) The facility failed to establish and follow a written policy on permitting resident to return to the facility after she was hospitalized . These failures could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal processes. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (memory loss), acute kidney disease, cyst of pancreas (swollen), cognitive communication deficit (difficulty with thinking and language), insomnia (difficulty sleeping) and Covid-19 (viral infection). Record review of Resident #1's admission MDS assessment, dated 06/09/23, reflected the resident had a BIMS score of 13, which reflected the resident was cognitively intact. Section BO300 indicated Page 1 of 6 676499 676499 02/26/2024 Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082

F 0622 moderate difficulty in hearing. Resident #1 required limited assistance with most ADLs. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's, undated, care plan reflected a care area with risk of complication and poor quality of life due to, use of anti-depressant medication related to depression and insomnia. There was no care plan for behavioral issues. Residents Affected - Few Record review of Resident #1 history and physical, dated 02/13/24, reflected: History of present illness: 95 F (female) nursing resident with history of age-related dementia, HTN, HLD , pancreatitis cyst on thyroid disease, admitted in [DATE] for GLF (ground level fall) and acute respiratory failure, for covid-19 infection and pneumonia, discharged back to SNF (skilled nursing facility). Patient has been confused for last 1 week, lately showing aggressive behavior, went out of SNF twice, requiring 2-3 people to bring her back to SNF. Three of her sons brought her to the ER today, patient was treated recently for UTI, patient was started on medications for aggressive behavior and anxiety recently at nursing home. On arrival to the ER patient was aggressive requiring IM Geodon and IM Versed, patient pulled IV again, received IV fluid bolus, during my evaluation, patient is sleeping, not able to give history During interview with SWH on 02/26/24 at 1:16 p.m., she said she was the Social Worker at the hospital where Resident #1 was transferred for evaluation and treatment of altered mental status with agitation and flight risk. The SWH explained the family member reported the facility called them to come pick up the resident. The family member and his brothers stated the facility declined to call for an ambulance and the family was forced to transport her to the hospital to keep the resident from leaving the facility. The SWH noted the facility notified the family member that they could no longer meet Resident #1's needs and asked she not to be brought back. The SWH explained she spoke with the DON who confirmed they were not able to meet her needs because in the last 24 hours she attempted to exit seek and they did not have a secured unit. The DON noted even if the problem was an underlying medical issue, they would not take the resident back. The SWH stated they treated and stabilized Resident #1 and was ready to discharge the resident to the facility. She contacted the facility who said they were not taking Resident #1 back because they could not meet her care needs. The SWH stated the hospital was not able to find a facility that would take the resident. During interview with CNA B on 02/23/24 at 11:05 a.m., she said she was the aide responsible for Resident #1 and was present when the resident was transferred to the hospital. CNA A explained the resident was exit seeking and was trying to leave the facility. She stopped the resident and she was ramping her leg with the walker. She notified the nurse and the DON. When the DON arrived, the resident was saying she wanted to jump in front of a car and die. CNA A did not calm down. She stated LVN A called the family member to come and sit with the resident. The family members arrived and decided to drive Resident #1 to the hospital. In an interview with LVN A on 02/23/23 at 11:16 a.m., she said she was the charge nurse responsible for Resident #1 during the morning shifts. LVN A explained she was the nurse who transferred the resident to the hospital because she tried to get out of the facility. She stated Resident #1 had COVID-19 which affected the resident's behavior. LVN A said she called the family members to come and pick her up because the ambulance would not take the resident with her behavior. The resident was trying to leave the facility and was hitting the family member with her walker. The family members decided to drive the resident to the hospital for evaluation and treatment. 676499 Page 2 of 6 676499 02/26/2024 Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082

F 0622 Level of Harm - Minimal harm or potential for actual harm In an interview with RP D on 02/23/24 at 11:39 a.m., he said Resident #1 was stabilized in the hospital and ready to leave to a facility. RP D explained the hospital told him the facility refused to take the resident back. RP D said the hospital was unable to find another facility for the resident. The hospital gave him a list. He visited 2-3 of the facilities on the list but they would not take Resident #1 because of her behavior. RP D noted he was confused and didn't know what to do. Residents Affected - Few During an interview with the DON on 02/23/2023 at 1:32 p.m., she said she was the DON and familiar with Resident #1. The DON explained Resident #1 was transferred to the hospital for suicidal ideation and exit seeking and did not return to the facility. The DON said the resident almost left the facility because she wanted to go to the road for a truck to run over her. The resident tried to drag the roommate out of bed to shower. The next day the resident attempted to get out of the facility before CNA B caught her. The DON explained the facility could not send the resident to the hospital because the ambulance would not take her because of her behavior. The family was notified who decided to take the resident in their car to the hospital. The DON said when the hospital called to bring the resident back, she told them she should have a psych evaluation before they could take her back. The DON was asked to provide information about the discharge of Resident #1. She said they did not have documentation because she was not planning on discharging Resident #1 when she went to the hospital. She stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process 4) Discharge summary 5) Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) 676499 Page 3 of 6 676499 02/26/2024 Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082

F 0622 Required 30-day notice to Resident #1 Level of Harm - Minimal harm or potential for actual harm 9) No communication with receiving facility Residents Affected - Few . During interview with Phy P on 02/26/24 at 1:55 p.m., he said he was the doctor for Resident #1. Phy P stated he did not necessarily order Resident #1's transfer to the hospital. The DON told her, she informed the hospital they needed to have a psych evaluation before the resident could come back. Phy P stated she was not involved with the facility process of deciding who to admit or not. She said she did not discharge the resident. Record review of the facility policy on Admission, Transfer and Discharge, revised December 2016, reflected: Policy Statement When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Policy Interpretation and Implementation I. Each resident will be permitted to remain in the facility, and not be transferred or discharged unlessa. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. The health of individuals in the facility would otherwise be endangered . 676499 Page 4 of 6 676499 02/26/2024 Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082

F 0622 When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Few The basis for the transfer or discharge. b. That an appropriate notice was provided to the resident and/or legal representative. c. The date and time of the transfer or discharge. d. The new location of the resident. 676499 Page 5 of 6 676499 02/26/2024 Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2) reviewed for infection control practice. Residents Affected - Few LVN A failed to perform hand hygiene and change gloves while providing wound care to Resident #2. These failures could place residents at risk for the spread of infection. Findings include: Record review of Resident #2's face sheet, dated 02/23/24, reflected a 57- year- old female who was admitted to the facility on [DATE]. with diagnoses of pressure ulcer of left hip, gastronomy, dysphagia, anxiety disorder and severe intellectual disability. Record review of Resident #2's quarterly MDS assessment, dated 01/15/24, reflected Resident #2 required total assistance with most activity of daily living (ADLs) and two-person assist. Resident #2 was always incontinent of bowel and always of bladder. Record review of Resident #2's care plan, dated 10/30/22, reflected the resident was care planned for pressure ulcers to the left hip. Record review of physician orders for February 2024 for Resident #2 reflected: Cleanse wound to left hip with wound cleanser, apply alginate calcium with silver, apply daily. Cover with gauze island dressing every shift for wound care. Observation of Resident #2's pressure ulcer on 02/23/24 at 12:03 p.m. revealed LVN E did not wash her hands but donned gloves before the start of care. She did not prepare a clean field before commencing care. LVN E took her supplies to the resident room and placed on her bed. She was holding the supplies in one hand and used the other hand to move the resident. LVN E did not change her gloves. She removed the old dressing which revealed a thick moist wound on the left hip. LVN E cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean dressing and placed on Resident #2's wound. LVN E picked up the trash and walked out of the room without washing her hands. In an interview on 02/23/24 at 12:15 p.m. with LVN E, she revealed she should have washed her hands before starting care and changed her gloves during care. LVN E also revealed she should have changed her gloves before retrieving a clean dressing and placing on Resident #2's wound. LVN E explained she had been employed in the facility about 1 month and received infection control training during orientation. She said the resident could acquire an infection when she did not follow good infection control practices which included washing hands before commencing care. During an interview with the DON 02/12/24 at 11:20 a.m., she stated she was aware of some of the concerns raised about infection control. She stated the staff were expected to wash their hands and don gloves before and after providing care. 676499 Page 6 of 6