Health inspection·January 29, 2026

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, before a resident was transferred or discharged , the resident and the resident's representative was notified of the transfer or discharge and the reason for the move in writing and in a language and manner they understood for 1 of 3 residents (Resident #1) reviewed for transfer and discharge rights.The facility failed to notify Resident #1's representative of the transfer with the reasons for the move in writing in a language and manner they understand. This failure could place residents at risk of not receiving an advocate who could inform them of their options, rights, and the added protection from being inappropriately transferred or discharged . Findings include: Record review of Resident #1's face sheet, dated 1/29/26, revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Cerebral infarction (a type of ischemic stroke caused by a blockage in blood vessels supplying the brain, leading to tissue death (necrosis) due to oxygen deprivation), Alzheimer's disease, and hypertensive heart/chronic kidney disease. discharge date revealed 1/24/26, length of stay 1 day, discharge to Facility B with hospice services. Record review of Resident #1's Progress Notes revealed, effective date of discharge 1/24/26, discharge transportation method to Facility B: ambulance picked up Resident #1 from the facility and transported to Facility B. During an interview on 1/29/26 at 10:15 AM, Family Member #2 stated she did not sign any documents or agree to have Resident #1 moved to another facility. She stated the hospice company called her on 1/24/26 and stated Resident #1 was to be moved to another facility. She stated Facility #2 never called her or let her know. She stated she worked with the hospice company regarding the transfer. During an interview on 1/29/26 at 12:55 PM, the Administrator stated Resident #1 was due to come into the facility as dually certified and he would be on the skilled side. He stated once Resident #1 got to the facility an assessment was completed, and they found that Resident #1 did not meet qualifications for receiving hospice and physical therapy services, which changed their services provided to Resident #1. He stated on the evening of 1/23/26, he spoke with the hospice company and Resident #1 could not stay at the facility. He stated he did not have any documentation from a physician order for the transfer. He stated he did not have any family approval documentation for the transfer. He stated he did not have the documentation because he believed HL should have handled everything including the documentation. During an interview on 1/29/26 at 1:25 PM, the HL stated she went to the facility the day Resident #1 was admitted . She stated everything was set up and everything was ready for Resident #1 to stay at the facility receiving end of life services through the hospice company. She stated on 1/24/26 she received multiple calls from the administrator stating that due to Resident #1 not meeting for qualifications for both hospice and physical therapy services the hospice company must get Resident #1 out of his facility. She stated she told the administrator it was not that simple and there was a process to moving Resident #1 to another facility. She stated the administrator did not care and it was Page 1 of 2 745060 745060 01/29/2026 St. Juanita Retirement and Rehab 3215 Ymca Drive San Angelo, TX 76904

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few their responsibility to get Resident #1 out. She stated the only reason the hospice company set up to get Resident #1 out of the building was because the administrator began to yell and cuss at not only herself but her nurse. She stated the process was not followed, but Resident #1 was moved for the safety of Resident #1 and his family. Record review of the, undated, Facility policy, Your Rights and Protections as a nursing home resident revealed: the nursing home has to safely and orderly transfer or discharge you and give you proper notice of bed-hold and/or readmission requirements. 745060 Page 2 of 2