Every finding on record at Southampton Rehabilitation and Healthcare Center

Based on resident representative interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure a safe discharge to the community for two of three residents in the survey sample (Residents #1 and #2). Residents #1 and #2 were discharged to a lower level of care in the community without a documented basis for the discharge, a prior discharge plan, identification or verification of needed care/services, involvement of the interdisciplinary team, preparation/orientation for the residents and without involvement or consent from the legal guardian (for Resident #1). This resulted in the identification of immediately jeopardy regarding failure to provide a safe, appropriate discharge to the community.The findings include:1. Resident #1, residing in the nursing facility for over three years, was discharged to independent housing that provided no direct supervision, assistance with ADLs [activities of daily living] or medication administration. The facility documented no basis for the discharge and developed no discharge plan of care prior to the discharge that included goals or identification of the resident's care needs in the community. Facility documents referenced R1's discharge location as a group home. This location was not a licensed group home but an unsupervised independent living apartment. The facility provided no orientation for R1 of the housing location. R1 was discharged to this independent housing situation with no arrangements for any services and without any involvement or consent of the resident's legal guardian. Resident #1 (R1) was admitted to the facility with diagnoses that included muscle wasting/atrophy, diabetes, magnesium deficiency, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, insomnia, affective mood disorder, compulsive sexual behaviors, atherosclerotic heart disease, cerebral infarction and vitamin deficiency. The minimum data set (MDS) dated [DATE] assessed R1 with moderately impaired cognitive skills and as requiring set-up/touch assistance for eating, dressing, hygiene and ambulation along with occasional incontinent of bowel/bladder. Section Q. of this MDS documented that the resident did not want to be asked about returning to the community on this or any other MDS assessments. R1 had resided in the nursing facility for over 3.5 years at the time of discharge on [DATE]. The clinical record documented R1 was adjudicated incapacitated and included a court order dated 2/23/22 for the appointed guardian to make all decisions indefinitely for R1, including living arrangements, placements and finances.R1's clinical record documented the resident discharged to a group home on 9/30/25. The clinical record documented no involvement or consent from the legal guardian regarding the discharge. R1's clinical record included no documented basis for the discharge from a physician or provider. The clinical record documented comments from the resident about discharging to a group home, but included no discharge plan, rationale for the discharge and no documented request from the resident or the legal guardian about a desire to leave the nursing facility. It was unclear from the clinical record what prompted R1's discharge to the community. There was no record of care plan review or involvement from the interdisciplinary team regarding R1's discharge. The last review of R1's comprehensive care plan prior to the 9/30/25 discharge was eight months earlier on 1/21/25 and that care plan indicated the resident had no plans to discharge from the facility. Review of R1's clinical record revealed a psychiatric nurse practitioner (NP) assessed R1 on 9/3/25 and documented, .[R1] mentions that he is supposed to be moving soon, although he is unsure of the destination .A licensed clinical social worker (LCSW) documented on 9/4/25, .Pt [patient] reports feeling slightly anxious/excited stating he will be moving to a group home which will provide more independence, decrease in number of residents/roommates .states [R1] is looking forward to cooking meals, getting outside more frequently, and engage in meaningful activities . On 9/11/25, the resident's physician conducted a recertification assessment that indicated the resident was appropriate for nursing home placement and made no mention of discharge to the community. The 9/11/25 recertification note documented, .with history of multiple medical problems .review of all medications and medical record .Discussed with the nursing staff. Recommend to continue with all other medications, monitor labs and observe fall precautions .resident is appropriate for nursing home care and requires significant help with ADLs and has history of multiple medical problems .On 9/16/25, a LCSW documented, .Pt reports he has some anxiety over his new upcoming placement in a group home .Processed emotions around moving to a group home .R1 was assessed by the NP on 9/18/25 and 9/25/25 with no mention of any discharge plans. A social services note dated 9/26/25 documented, .Writer discussed resident discharge with resident and Group Home .Resident set to discharge to .Group home on 9/29. The NP documented a progress note on 9/29/25 stating, .with a complex medical history who is currently being evaluated for discharge. Per the assigned social worker, [R1] is scheduled for discharge today to a community-based group home .[R1] will be under the care of a designated primary care provider affiliated with the group home, ensuring continuity of medical oversight .Given his current clinical stability and the supportive structure of the group home environment [R1] is considered appropriate for discharge. Ongoing monitoring and management of his chronic conditions will be coordinated through his new primary care provider, with attention to both his physical and mental health needs .R1's Discharge summary dated [DATE] listed the resident's discharge destination as a Group Home with a street address and apartment number listed. The guardian's name and phone number were listed on the form but there was no documentation the guardian was notified of the discharge. The discharge summary documented that pre and post discharge medications had been reconciled. The resident's medication list on the discharge summary did not include aspirin, atorvastatin, ferrous sulfate, spironolactone and Trulicity. The NP listed in the 9/29/25 note, that these medications were among those to continue after discharge for treatment of cerebral infarction, hyperlipidemia, vitamin deficiency, congestive heart failure and diabetes. The discharge summary included no education/instruction to the resident about use of the Trulicity injection pen for diabetic management. The resident was not assessed at the nursing facility to self-administer any medication including injecting Trulicity. The discharge summary listed the resident was responsible for scheduling follow up appointments with a primary physician and was educated on the importance of follow up visits. A primary provider's name was listed on the discharge summary but spaces for the provider's office address and phone number were blank. It was unclear from the clinical record if the resident had a cell phone or access to a phone at the discharge destination and the discharge summary made no mention of money management or finance needs/concerns.A social services note dated 9/29/25 documented, .Resident discharge postponed to 9/30. Group Home providing transport .A social services note dated 10/7/25 documented R1's guardian had called concerning the resident's discharge and clarification of contact numbers. This note documented, .Writer informed [R1's legal guardian] to feel free to reach out regarding resident .On 2/4/26 at 1:40 p.m., R1's legal guardian (other staff #1) was interviewed about the resident's discharge on [DATE]. The guardian stated she was not aware of the resident's discharge until 10/6/25 when a local hospital social worker (SW) called and reported that the resident had been found wandering the street with his belongings and was brought to the emergency department. The guardian stated the hospital SW told her the resident had been living in a group home. The guardian stated she had no idea that R1 was living in the community and had not been notified or consulted about the discharge. The guardian stated she talked with the facility's social worker (other staff #3) on 10/7/25 after the hospital notified her of the resident's status in the community. The guardian stated the facility social worker (other staff #3) claimed she had reached out to discuss the discharge plan. The guardian stated she never received a call or message from the facility's social worker and that she had talked with no one from the facility regarding R1 discharging from the facility. The guardian stated the resident should never have been discharged without her consent or input in the discharge plan/destination. The guardian stated if she had known, she would have visited the potential location to be sure it was a safe place and that the resident had services/care needed. The guardian stated she researched R1's discharge location and stated it was not a licensed group home but an apartment. The guardian stated, [R1] was living in an apartment with other men. The guardian stated the resident experienced no injuries and had since been placed in another nursing facility. The guardian stated, I was never contacted .This should not have happened . On 2/4/26 at 2:10 p.m., the facility's SW (other staff #3) and the regional SW (other staff #4) were interviewed about R1's discharge on [DATE]. The SW stated the plan for R1 was to discharge to the community. The SW stated she spoke to the legal guardian and then stated she did not speak directly to the legal guardian but that she had left a message with someone at a desk, asking the guardian to call her. The SW stated R1 was able to do a lot for himself, had no family and had asked about going to a group home. When asked if the discharge destination was a licensed group home, the SW was not sure and stated the owner came and assessed the resident prior to discharge. When asked if she or the resident visited the discharge destination prior to discharge, the SW stated, No. When asked about what prompted R1's discharge from the facility since he had been there over three years, the SW stated the resident had approached her about going back to the community and that the discharge location would provide the resident increased freedoms. The SW stated she became aware of the destination after the owner had visited the facility and left a business card. The SW stated again she contacted the legal guardian multiple times but did not know how many times or when the contacts were made. The social worker provided no evidence the guardian had been contacted or involved in R1's discharge.On 2/4/26 at 2:45 p.m., the owner of R1's discharge destination (other staff #2) was interviewed about the facility and services offered. The owner stated, We offer apartments and rooms. The owner stated the housing was independent living and that all those staying at the apartments were required to be independent with all ADLs. The owner stated the apartments were not a group home and the facility was not licensed by any state agency. The owner stated services provided included assistance with meal prep if requested and pill reminders but that no direct care or services were provided. The owner stated there was no medicine administration, only reminders to take medicines. The owner stated, We don't take anyone that needs assistance. The owner stated those that reside at the housing do their own thing and that some that stayed there had their own room and others shared a room. On 2/4/26 at 3:10 p.m., the facility's SW (other staff #3) and the regional SW (other staff #4) were interviewed again about R1's discharge location. The SW stated the owner met with R1, that R1 got along with the owner so she moved forward with plans for the discharge. The SW stated no other discharge destinations were considered or presented to the resident. The SW stated the owner had visited the resident, but she did not know the date and again stated she had not visited or seen the discharge location. When asked again about notification or involvement of the resident's legal guardian, the SW stated she called the guardian on 9/29/25 telling her of the discharge then stated it was late and that she had left a voice message. The SW stated the guardian did not call her until 10/7/25. The SW stated prior to 9/29/25, she had talked with someone at the desk, asking the guardian to contact her but that no one ever called her back. The SW stated R1 could do everything for himself and that she thought the housing was appropriate.On 2/4/26 at 3:45 p.m., the administrator was interviewed about concerns regarding R1's discharge on [DATE]. The administrator stated R1 was independent and that the resident had asked about wanting to leave the facility. The administrator stated R1's legal guardian should have been involved prior to the resident's discharge and that there should have been agreement/consent from the legal guardian about the discharge plans. A documented discharge plan was requested. On 2/5/26 at 8:30 a.m., the administrator presented a copy of R1's discharge summary and stated the plan/summary were all in one.On 2/5/26 at 8:40 a.m., the facility SW (other staff #3) and the assistant administrator (administration #2) were interviewed about R1's discharge. The assistant administrator stated there was only a discharge summary and no documented discharge plan. The assistant administrator stated she reviewed the clinical record and found no care plan meetings since January 2025 and the care plan for R1 had not been updated regarding any discharge plans. The SW was asked if R1 had a cell phone for use after discharge and the SW stated, I don't recall that [R1] had a cell phone. The SW presented no documentation indicating discharge goals or identified care needs/concerns regarding R1's return to the community. The SW stated she thought the group home was providing a physician and help with medications. Concerning consent from the legal guardian, the SW stated she talked with whoever picked up at the main phone number and that she shared that there were discharge plans for R1. The SW stated she did not know when those call attempts were made or with whom she left a message. The SW stated there was no written letter sent to the resident or the guardian about the discharge. When asked again about the rationale for R1's discharge at this destination, the SW stated the owner was a registered nurse, was familiar with R1, that the destination had a physician to provide care and that R1 could have a more regular life. When asked how R1 would get the Trulicity injection needed for diabetic management, the SW stated she thought the group home would assist the resident with medications. The SW stated she only had conversations with the housing owner and had no documented list of services provided by the discharge destination.On 2/5/26 at 9:15 a.m., the NP (other staff #5) that routinely cared for R1 was interviewed about the resident's discharge on [DATE]. The NP stated she had taken care of R1 for several years and was very familiar with the resident's needs/care. The NP stated R1's condition had been stable in 2025 with no significant decline or improvement in condition. The NP stated R1 had mentioned the discharge, was happy to go and that the resident was alert and oriented. The NP stated R1 needed encouragement and cueing with hygiene but otherwise was independent with ADLs. The NP stated, I understood that [R1] was going to a group home and they had a provider. The NP stated she was informed the group home had their own physician/provider and that medication administration and structured services would be provided. The NP stated she was not familiar with the named destination, had been informed it was a group home and that she had not been made aware the location was an independent living situation. The NP stated R1 would not thrive on his own. The NP stated R1 required cueing for hygiene and required help with medication administration. The NP stated nursing administered medications to R1 at the nursing facility. The NP stated she was not sure if R1 would know when to take prescribed medicines. The NP stated she had not communicated with the legal guardian about the discharge. The NP stated she did not know what prompted the discharge. The NP stated she was never involved in discharge plans or a meeting about R1's discharge. The NP stated the facility's social worker communicated that arrangements had been made. The NP stated she was not aware the guardian was not notified or involved and thought the discharge destination was a licensed group home. The NP stated an independent living situation was not appropriate or safe for R1. The NP stated she gave the resident prescriptions for a 30-day supply of all discharge medications, including Trulicity. The NP stated R1 needed Trulicity for diabetic management and that the resident was not trained to give the injection prior to discharge. The NP stated she thought the group home would provide medication administration, including the Trulicity injection. The NP stated again independent living was not appropriate for R1 and that R1 needed assistance with medication administration and ongoing follow up by a primary medical provider. The NP stated appropriate/safe discharge destinations for R1 included another nursing facility or a structured group home with services. The NP stated R1 could not effectively manage money and again stated R1 needed help with medications. The NP stated that social services usually told her when a resident was ready for discharge. On 2/5/26 at 11:55 a.m., the licensed practical nurse unit manager (LPN #1) that routinely cared for R1 was interviewed. LPN #1 stated she did not know what prompted R1's discharge and that discharge planning was handled by social services. LPN #1 stated R1 was mostly independent with ADLs and that nurses administered the resident's medications. LPN #1 was not aware of any education to R1 about injecting Trulicity prior to discharge and that the resident did not self-administer any medications in the nursing facility. LPN #1 stated she thought R1 was going to a place that administered medications. LPN #1 stated all the resident's required medications should have been listed on the discharge summary. The survey team verified that R1's discharge destination was not included in the list of licensed group homes in the state. The owner's business card listed the owner's name and business address but referenced no services provided. The facility's policy titled Transfer or Discharge (revised March 2025) documented, .Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record .When the facility transfers or discharges a resident, information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider .If the basis for the discharge is that the resident's health has improved sufficiently so that the resident no longer needs the care of the facility, the resident's physician (or provider) documents information about the resident's condition and the appropriateness of the discharge . For residents discharging to the community, this policy documented, See Discharge Summary and Plan.The director of nursing (DON) was on leave and not available for interview during the survey. R1's hospital records for 10/6/25 were requested but not received prior to the end of the survey. 2. For Resident #2 (R2), who was dependent on assistance with activities of daily living (ADLs), medication administration, and required dialysis treatment, the facility staff failed to ensure a safe discharge and discharged the R2 to an independent living.On 2/5/26 at 10:40 AM, a closed record review was conducted of R2's clinical record. According to the census tab, R2 resided at the facility 04/15/22-10/31/25. According to R2's diagnosis listing, the resident's diagnosis included, but were not limited to: Non-ST Elevation (NSTEMI) Myocardial Infarction [heart attack], hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, type 2 diabetes mellitus with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, other abnormalities of gait and mobility, and hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease.According to the Discharge Summary dated 10/31/25, from the medical provider (nurse practitioner) it read in part, . He was seeing this afternoon after dialysis. He reports that he's having increased queasiness after dialysis, but he states that it is not nausea and he does not need any medication to manage his symptoms .Patient is stable for discharge to group home with home health PT OT [physical therapy and occupational therapy] Condition at discharge stable.According to R2's care plan a focus area initiated 7/9/24, read, [R2's name redacted] has an ADL Self Care Performance Deficit r/t [related to] muscle wasting, CVA, L sided hemiplegia, DM, ESRD, Heart Failure, Glaucoma, and depression. Interventions for this intervention read, I use a wheelchair ., I require supervision/setup with bathing, . I require x 1 assistance with dressing, . I require set-up assistance with eating and drinking, . I require x 1 assistance with grooming/personal hygiene, I require x 1 assistance with toileting, and I require 1 person assistance with transfers. I am able to stand and pivot.R2's care plan also the resident was incontinent of bowel. Another focus area dated 7/25/24, which was active at the time of discharge, read, [R2's name redacted] wishes to remain long-term care at this facility.R2's most recent minimum data set (MDS), an assessment tool, with an assessment reference date of 8/18/25, noted that R2 was cognitively intact as indicated by a brief interview for mental status score of 15. That same assessment noted in Section GG, that R2 was Dependent for toileting hygiene, shower/bathe self, sit to stand, sit to lying, chair/bed-to-chair transfer, and toilet transfer. For dressing and personal hygiene R2 was coded as having required Supervision or touching assistance. According to a Uniform Assessment Instrument (UAI) dated 10/1/25, it indicated that R2 required help with bathing, toileting, eating, dressing and transferring. It also indicated that R2 needed physical assistance with mobility, assistance with meal preparation, housekeeping, laundry, money management, transport, shopping, using the phone, and home maintenance. According to the form within the UAI assessment titled, Medicaid Funded Long-Term Care Services and Supports Authorization Form (DMAS-96), indicated that nursing home level of care was needed and authorized.Within R2's clinical record, there was not documented evidence of any discharge planning to include medication administration, medication education or training, management of the dialysis access site, medical equipment needs, home health being arranged as per physician orders/documentation, etc. The only notation was an entry by the social worker dated 8/28/25 that read, Writer received notice, resident is interested in discharging to a group home. Resident met with group home representative. UM aware, referral paperwork in reviewal. No discharge date in place. The next entry by the social worker was dated 9/29/25 that read, Resident discharge postponed to 10/31.On 2/4/26, during a conversation with the owner of the facility where R2 discharged to, the owner reported the facility was independent living. The owner reported they do not staff the facility, do not provide any care, or administer medications. The only service(s) the owner reported they provide, is pill reminders and meal preparation, if they want it. The owner further confirmed that her business is not licensed by any regulatory authority and is more like where people are just renting rooms. On 2/5/26at 11:52 AM, an interview was conducted with the facility's social worker (SW). The SW reported, He [R2] was a long-term resident here for a while, he did discharge from facility per his request. The lady had come here and was touring, he met the owner. He was eager to discharge, he has been here a while, I went over it with him and made sure transport to dialysis was set to continue and the owner was aware. When asked what prompted R2 to discharge since he had been at the facility for over three years. The SW said, He requested it. When he found out there were opportunities to go to the community and get a fresh start. The SW was asked if she had inquired about the facility, level of care, or visited the facility, she indicated she had not visited the place but thought it was a group home. When asked if it was an assisted living facility, the SW said, No. it is a mix of independent but need nursing care. When asked if they had around the clock care, the SW said, I will have to double check. The SW confirmed she wasn't aware of what services the place did or did not offer and hadn't asked, she was just told it was a group home.On 2/5/26 at 12:05 PM, an interview was conducted with the nurse practitioner (NP), who was R2's medical provider. The NP reported that R2 was a dialysis patient and discharge was delayed due to setting up transport to and from dialysis. The NP went on to report that R2 went to a group home that she described as a little nursing home, staffed by certified nursing assistants (CNAs) and nurses. When the NP was made aware that R2 was discharged to an independent living setting she stated she was not aware and felt R2 needed a group home. The NP went on to say, Oh Wow! It needs to be people who know how to take care of him as a dialysis patient with 24-hour care with nurses and CNAs. The social worker told me it was a group home house by medical care. The NP went on to explain that R2 had one arm that was very spastic from a CVA [stroke] and he's not able to manage medications on his own. This is crazy, I thought was a group home. Wow. Is he ok?On 2/5/26 at 12:21 PM, an interview was conducted with licensed practical nurse #2 (LPN #2). LPN #2 recalled that R2 could help with ADL's but needed help. His arm was impaired. LPN #2 reported that R2 did not self administer medications at the facility and didn't manage his dialysis port himself. On 2/5/26 at 12:30 PM, an interview was conducted with LPN #1, who was the unit manager. The unit manager was asked about R2 and said, He went to dialysis Tuesday, Thursday, Saturday. He had weakness, one arm was contracted. He was able to ambulate with a walker with assistance, he could feed himself with set-up. He used a wheelchair for long distances, was oriented x 3. LPN #2 recalled that R2 had a cell phone, could tell you when he needed to go to the bathroom, but needed assistance to pull up his clothes. The unit manager went on to explain that the resident needed assistance to be safe due to weakness on one side. During the above interview, the unit manager said that R2 said he wanted to get back out in the community and be more social. He discharged to a group home. When asked if R2 was safe to live on his own, the unit manager said, I wouldn't say so, he is a fall risk. When asked if she was aware that he was discharged to an independent living, the unit manager said she was not aware, she thought the lady that came to visit and picked up his prescriptions ran a group home. The unit manager went on to say, I thought it was a group home where people live together, someone administers the medications and had 24-hour care. I thought it was like a house with people there 24/7. On 2/5/26 at 2:08 p.m., the survey team contacted state agency supervision and discussed concerns regarding the facility's failure to provide safe, appropriate discharges for Residents #1 and #2. On 2/5/26 at 2:15 p.m. the administrator, assistant director of nursing and regional nurse consultant were advised that immediate jeopardy (IJ) was identified regarding the facility's failure to provide safe, effective discharges for Residents #1 and #2. The administrator was informed that immediate action was needed for development and implementation of a discharge planning process to ensure safe and appropriate discharges for residents and a documented plan of IJ removal was requested.On 2/5/26 at 4:50 p.m., a plan of IJ removal regarding discharge planning was provided by the facility. The plan was reviewed and approved by the state agency survey team/supervision and included the following.Immediate Jeopardy Plan of Removal1. Effective immediately, all discharges to lower level of care are paused pending interdisciplinary review. Social Service, Assistant Administrator and Assistant Director of Nursing completed a retrospective review of all 78-resident discharged to a lower level of care from 9/30/25 to present. The questions included Are Medication administration including injectables needs met and Are needs for Activity of Daily Living met. Residents identified at risk were contacted, reassessed and support/ services arranged or offered as appropriate.2. A Discharge Planning Protocol was implemented requiring: Ongoing IDT collaboration establishing discharge plan, physician order aligned with actual discharge location, resident/representative participation and consent, assessment of functional status and care needs, confirmation of medication access and administration ability, and confirmed follow-up appointments and services. Residents that require assistance with Activities of Daily Living, Dialysis, medications, or supervision may not discharge to a lower level of care without documented support systems.3. All IDT members will be educated by the Regional Director of Operations or designee to include Administrator, Assistant Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, Business Office, Social Services, Therapy, Licensed Nurses, Certified Nursing Assistants, and Providers. The education included Appropriate Discharge planning utilizing the Transfer and Discharge Policy and F627 requirements. Education included: ongoing IDT collaboration establishing discharge plan, physician order aligned with actual discharge location, resident/representative participation and consent, assessment of functional status and care needs, confirmation of medication access and administration ability, confirmed follow-up appointments and services. Residents that require assistance with Activities of Daily Living, Dialysis, medications, or supervision may not discharge to lower level of care without documented support systems. Any staff who are not present for immediate education will be educated prior to working their next scheduled shift. The plan documented actions taken would be completed on 2/5/26 by 11:00 p.m. On 2/6/26 starting at 8:45 a.m., the survey team verified that phone contacts and/or letters were issued to all residents discharged to lower level of care since 9/30/25. A documented discharge protocol was implemented that included a checklist of the required items with completion mandatory prior to any discharges to a lower level of care. The survey team verified education to staff members was conducted as listed. Implementation of the IJ removal plan was deemed sufficient and completed as documented. The immediacy was removed as of 2/6/25 at 10:00 a.m. The scope/severity was reduced to level 2 isolated following the removal of immediate jeopardy.

Based on resident representative interview, staff interview, facility document review and clinical record review, the facility staff failed to provide medically related social services regarding discharge planning for two of three residents in the survey sample (Residents #1 and #2). The findings include:1. Facility staff failed to provide social services to ensure a safe discharge to the community for Resident #1 (R1). R1, residing in the nursing facility for over three years, was discharged to independent housing that provided no direct supervision, assistance with ADLs [activities of daily living] or medication administration. The social worker responsible for discharge planning failed to ensure a discharge plan of care was in place prior to the discharge that included goals, identification of the resident's care needs in the community, involvement of the interdisciplinary team and consent from the resident's legal guardian. The social worker referenced R1's discharge location as a group home and failed to verify what services were provided at this destination to meet the resident's needs. The location was not a licensed group home but an independent living apartment. Social services failed to provide orientation for R1 to the new housing location. Resident #1 (R1) was admitted to the facility with diagnoses that included muscle wasting/atrophy, diabetes, magnesium deficiency, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, insomnia, affective mood disorder, compulsive sexual behaviors, atherosclerotic heart disease, cerebral infarction and vitamin deficiency. The minimum data set (MDS) dated [DATE] assessed R1 with moderately impaired cognitive skills and as requiring set-up/touch assistance for eating, dressing, hygiene and ambulation along with occasional incontinent of bowel/bladder. Section Q. of this MDS documented that the resident did not want to be asked about returning to the community on this or any other MDS assessments. R1 had resided in the nursing facility for over 3.5 years at the time of discharge on [DATE]. The clinical record documented R1 was adjudicated incapacitated and included a court order dated 2/23/22 for the appointed guardian to make all decisions for R1, including living arrangements, placements and finances on an indefinite basis. R1's clinical record documented the resident discharged to a group home on 9/30/25. The clinical record documented no involvement or consent from the legal guardian regarding the discharge. R1's clinical record included no documented basis for the discharge from a physician or provider. The clinical record documented comments from the resident about discharging to a group home, but included no discharge plan, rationale for the discharge and no documented request from the resident or the legal guardian about a desire to leave the nursing facility. It was unclear from the clinical record what prompted R1's discharge to the community. There was no record of care plan review or involvement from the interdisciplinary team regarding R1's discharge. The last review of R1's comprehensive care plan prior to the 9/30/25 discharge was eight months earlier on 1/21/25 and that care plan indicated the resident had no plans to discharge from the facility. Review of R1's clinical record revealed a psychiatric nurse practitioner (NP) assessed R1 on 9/3/25 and documented, .[R1] mentions that he is supposed to be moving soon, although he is unsure of the destination . A licensed clinical social worker (LCSW) documented on 9/4/25, .Pt [patient] reports feeling slightly anxious/excited stating he will be moving to a group home which will provide more independence, decrease in number of residents/roommates .states [R1] is looking forward to cooking meals, getting outside more frequently, and engage in meaningful activities . On 9/11/25, the resident's physician conducted a recertification assessment that indicated the resident was appropriate for nursing home placement and made no mention of discharge to the community. The 9/11/25 recertification note documented, .with history of multiple medical problems .review of all medications and medical record .Discussed with the nursing staff. Recommend to continue with all other medications, monitor labs and observe fall precautions .resident is appropriate for nursing home care and requires significant help with ADLs and has history of multiple medical problems . On 9/16/25, a LCSW documented, .Pt reports he has some anxiety over his new upcoming placement in a group home .Processed emotions around moving to a group home . R1 was assessed by the NP on 9/18/25 and 9/25/25 with no mention of any discharge plans. A social services note dated 9/26/25 documented, .Writer discussed resident discharge with resident and Group Home .Resident set to discharge to .Group home on 9/29. The NP documented a progress note on 9/29/25 stating, .with a complex medical history who is currently being evaluated for discharge. Per the assigned social worker, [R1] is scheduled for discharge today to a community-based group home .[R1] will be under the care of a designated primary care provider affiliated with the group home, ensuring continuity of medical oversight .Given his current clinical stability and the supportive structure of the group home environment [R1] is considered appropriate for discharge. Ongoing monitoring and management of his chronic conditions will be coordinated through his new primary care provider, with attention to both his physical and mental health needs . R1's Discharge summary dated [DATE] listed the resident's discharge destination as a Group Home with a street address and apartment number listed. The guardian's name and phone number were listed on the form but there was no documentation the guardian was notified of the discharge. The discharge summary documented that pre and post discharge medications had been reconciled. The discharge summary included no education/instruction to the resident about use of the Trulicity injection pen for diabetic management. The resident was not assessed at the nursing facility to self-administer any medication including injecting Trulicity. The discharge summary listed the resident was responsible for scheduling follow up appointments with a primary physician and was educated on the importance of follow up visits. A primary provider's name was listed on the discharge summary but spaces for the provider's office address and phone number were blank. It was unclear from the clinical record if the resident had a cell phone or access to a phone at the discharge destination and the discharge summary made no mention of money management or finance needs/concerns. A social services note dated 9/29/25 documented, .Resident discharge postponed to 9/30. Group Home providing transport . A social services note dated 10/7/25 documented R1's guardian had called concerning the resident's discharge and clarification of contact numbers. This note documented, .Writer informed [R'1 legal guardian] to feel free to reach out regarding resident . On 2/4/26 at 1:40 p.m., R1's legal guardian (other staff #1) was interviewed about the resident's discharge on [DATE]. The guardian stated she was not aware of the resident's discharge until a local hospital social worker (SW) called on 10/6/25 and reported that the resident had been found on the street with his belongings and was brought to the emergency department by authorities. The guardian stated the hospital SW told her the resident had been living in a group home. The guardian stated she had no idea that R1 was living in the community and had not been notified or consulted about the discharge. The guardian stated she talked with the facility's social worker (other staff #3) on 10/7/25 after the hospital notified her of the resident's status in the community. The guardian stated the facility social worker (other staff #3) claimed she had reached out to discuss the discharge plan. The guardian stated she never received a call or message from the facility's social worker and that she had talked with no one from the facility regarding R1 discharging from the facility. The guardian stated the resident should never have been discharged without her consent or input in the discharge plan/destination. The guardian stated if she had known, she would have visited the potential location to be sure it was a safe place and that the resident had services/care needed. The guardian stated she researched R1's discharge location and stated it was not a licensed group home but an apartment. The guardian stated, [R1] was living in an apartment with other men. The guardian stated the hospital reported that R1 was found wandering in the community, that someone called 911 and the resident was taken to a local hospital by authorities. The guardian stated the resident experienced no injuries and had since been placed in another nursing facility. The guardian stated, I was never contacted .This should not have happened . On 2/4/26 at 2:10 p.m., the facility's SW (other staff #3) and the regional SW (other staff #4) were interviewed about R1's discharge on [DATE]. The SW stated the plan for R1 was to discharge to the community. The SW stated she spoke to the legal guardian and then stated she did not speak directly to the legal guardian but that she had left a message with someone at a desk, asking the guardian to call her. The SW stated R1 was able to do a lot for himself, had no family and had asked about going to a group home. When asked if the discharge destination was a licensed group home, the SW was not sure and stated the owner came and assessed the resident prior to discharge. When asked if she or the resident visited the discharge destination prior to discharge, the SW stated, No. When asked about what prompted R1's discharge from the facility since he had been there over three years, the SW stated the resident had approached her about going back to the community and that the discharge location would provide the resident increased freedoms. The SW stated she became aware of the destination after the owner had visited the facility and left a business card. The SW stated again she contacted the legal guardian multiple times but did not know how many times or when. The social worker provided no evidence the guardian had been contacted or involved in R1's discharge. On 2/4/26 at 2:45 p.m., the owner of R1's discharge destination (other staff #2) was interviewed about the facility and services offered. The owner stated, We offer apartments and rooms. The owner stated the housing was independent living and that all those staying at the apartments were required to be independent with all ADLs. The owner stated the apartments were not a group home and the facility was not licensed by any state agency. The owner stated services provided included assistance with meal prep if requested and pill reminders but that no direct care or services were provided. The owner stated there was no medicine administration, only reminders to take medicines. The owner stated, We don't take anyone that needs assistance. The owner stated those that reside at the housing do their own thing and that some that stayed there had their own room and others shared a room. On 2/4/26 at 3:10 p.m., the facility's SW (other staff #3) and the regional SW (other staff #4) were interviewed again about R1's discharge location. The SW stated the owner met with R1, that R1 got along with the owner so she moved forward with plans for the discharge. The SW stated no other discharge destinations were considered or presented to the resident. The SW stated the owner had visited the resident, but she did not know the date and again stated she had not visited or seen the discharge location. When asked again about notification or involvement of the resident's legal guardian, the SW stated she called the guardian on 9/29/25 telling her of the discharge then stated it was late and that she had left a voice message on that date. The SW stated the guardian did not call her until 10/7/25. The SW stated prior to 9/29/25, she had talked with someone at the desk, asking the guardian to contact her but that no one ever called her back. The SW stated R1 could do everything for himself. The social worker presented no information about what services, if any, R1 needed post-discharge or what services would be provided by the new facility. On 2/4/26 at 3:45 p.m., the administrator was interviewed about concerns regarding R1's discharge on [DATE]. The administrator stated R1 was independent and that the resident had asked about wanting to leave the facility. The administrator stated R1's legal guardian should have been involved prior to the resident's discharge and that there should have been agreement/consent from the legal guardian about the discharge plans. A documented discharge plan was requested. On 2/5/26 at 8:30 a.m., the administrator presented a copy of R1's discharge summary and stated the plan/summary were all in one. On 2/5/26 at 8:40 a.m., the facility SW (other staff #3) and the assistant administrator (administration #2) were interviewed again about R1's discharge. The assistant administrator stated there was only a discharge summary and no documented discharge plan. The SW was asked if R1 had a cell phone for use after discharge and the SW stated, I don't recall that [R1] had a cell phone. The SW presented no documentation indicating discharge goals or identified care needs/concerns regarding R1's return to the community. The SW stated she thought the group home was providing a physician and help with medications. Concerning consent from the legal guardian, the SW stated she talked with whoever picked up at the main phone number and that she shared that there were discharge plans for R1. The SW stated she did not know when those call attempts were made or with whom she left a message. When asked again about the rationale for R1's discharge at this destination, the SW stated the owner was a registered nurse, was familiar with R1, that the destination had a physician to provide care and that R1 could have a more regular life. When asked how R1 would get the Trulicity injection needed for diabetic management, the SW stated she thought the group home would assist the resident with medications. The SW stated she only had conversations with the housing owner and had no documented list of services provided by the discharge destination. On 2/5/26 at 9:15 a.m., the NP (other staff #5) that routinely cared for R1 was interviewed about the resident's discharge on [DATE]. The NP stated she had taken care of R1 for several years and was very familiar with the resident's needs/care. The NP stated R1's condition had been stable in 2025 with no significant improvement in condition. The NP stated R1 had mentioned the discharge, was happy to go and that the resident was alert and oriented. The NP stated R1 needed encouragement and cueing with hygiene but otherwise was independent with ADLs. The NP stated, I understood that [R1] was going to a group home and they had a provider. The NP stated she was led to believe the group home had their own physician/provider and that medication administration and structured services would be provided. The NP she was not familiar with the named destination, had been informed it was a group home and that she had not been made aware the location was independent living. The NP stated R1 would not thrive on his own. The NP stated R1 required cueing for hygiene and required help with medication administration. The NP stated nursing administered medications to R1 at the nursing facility. The NP stated she was not sure if R1 would know when to take prescribed medicines. The NP stated she had no contact with the legal guardian about the discharge. The NP stated she did not know what prompted the discharge. The NP stated she was never involved in discharge plans or a meeting about R1's discharge. The NP stated the facility's social worker communicated that arrangements had been made. The NP stated she was not aware the guardian was not notified or involved and thought the discharge destination was a licensed group home. The NP stated an independent living situation was not appropriate or safe for R1. The NP stated she gave the resident prescriptions for a 30-day supply of all discharge medications, including Trulicity. The NP stated R1 needed Trulicity for diabetic management and that the resident was not trained to give the injection prior to discharge. The NP stated she thought the group home would provide medication administration, including the Trulicity injection. The NP stated again independent living was not appropriate for R1 and that R1 needed assistance with medication administration and ongoing follow up by a primary medical provider. The NP stated appropriate/safe discharge destinations for R1 included another nursing facility or a structured group home with services. The NP stated R1 could not effectively manage money and again stated R1 needed help with medications. The NP stated that social services usually told her when a resident was leaving. On 2/5/26 at 11:55 a.m., the licensed practical nurse unit manager (LPN #1) that routinely cared for R1 was interviewed. LPN #1 stated she did not know what prompted R1's discharge and that discharge planning was handled by social services. LPN #1 stated R1 was mostly independent with ADLs and that nurses administered the resident's medications. LPN #1 was not aware of any education to R1 about injecting Trulicity prior to discharge and that the resident did not self-administer any medications in the nursing facility. LPN #1 stated she thought R1 was going to a place that administered medications. LPN #1 stated all the resident's required medications should have been listed on the discharge summary. On 2/6/26 at 8:32 a.m., the current director of social services (other staff #10) was interviewed about the services provided regarding R1's discharge. The social services (SS) director stated she was not working in the facility at the time of R1's discharge. The SS director stated discharge planning started for residents upon admission and the social worker was responsible for reviewing/updating discharge plans as needed and during care plan review meetings. The SS director stated if discharge plans changed, the responsible party/guardian would be involved along with the interdisciplinary care team, including the provider. The SS director stated the social worker duties included discharge planning and that the social worker was supposed to ensure that services needed were identified and arrangements made for provision of needed services after discharge. The facility's job description titled Social Worker (undated) documented, .The primary purpose of your job position is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of our Center's Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Director of Social Services and/or Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis . This job description documented administrative functions for the social worker included, .Participate in discharge planning, development and implementation of social care plan and resident assessments .Coordinate social service activities with other departments as necessary .Assist in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning (including collaboration with community agencies) .Interpret social, psychological, and emotional needs of the resident/family to the medical staff, attending physician, and other resident care team members .Involve the resident/family in planning objectives and goals for the resident .Participate in regularly scheduled reviews of resident discharge plans .Assist in developing a written plan of care .Encourage the resident/family to participate in the development and review of his/her plan of care .Assist in the scheduling of care plans and assessments to be presented and discussed at each committee meeting . This finding was reviewed with the administrator, assistant administrator, assistant director of nursing and regional nurse consultant during a meeting on 2/6/25 at 10:05 a.m. with no further information presented prior to the end of the survey. 2. For Resident #2 (R2), who was a dialysis patient, discharged to an independent living, the facility staff failed to provide medically related social services with regards to discharge planning. On 2/5/26 at 10:40 AM, a closed record review was conducted of R2's clinical record. According to the census tab, R2 resided at the facility for three and a half years, from 04/15/22-10/31/25. According to R2's diagnosis listing, the resident's diagnosis included, but were not limited to: Non-ST Elevation (NSTEMI) Myocardial Infarction [heart attack], hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, type 2 diabetes mellitus with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, other abnormalities of gait and mobility, and hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. According to the Discharge Summary dated 10/31/25, from the medical provider (nurse practitioner) it read in part, . He was seeing this afternoon after dialysis. He reports that he's having increased queasiness after dialysis, but he states that it is not nausea and he does not need any medication to manage his symptoms .Patient is stable for discharge to group home with home health PT OT [physical therapy and occupational therapy] Condition at discharge stable. According to R2's care plan a focus area initiated 7/25/24, which remained active until R2's discharge, read, [R2's name redacted] wishes to remain long-term care at this facility. Within R2's clinical record, there was not documented evidence of any discharge planning to include the residents needs prior to discharge, provision for medication administration post discharge, there was no evidence of medication education or training prior to discharge, nor any arrangements for management of R2's dialysis access site/port. The clinical record had no documentation of what R2's medical equipment needs would be, no evidence of home health being arranged as per physician orders/documentation, and no involvement of the interdisciplinary care plan team for R2's discharge other than a care plan meeting note dated 10/31/25. The only notation within R2's clinical record regarding discharge were two entries by the social worker. One note dated 8/28/25 that read, Writer received notice, resident is interested in discharging to a group home. Resident met with group home representative. UM [unit manager] aware, referral paperwork in reviewal. No discharge date in place. The next entry by the social worker was dated 9/29/25 that read, Resident discharge postponed to 10/31. There was no documentation of where the resident was discharging to other than an address on the document titled, MQS. IDT Care Plan Meeting Review dated the day of discharge, 10/31/25. The care plan meeting review form indicated that only nursing and social services were present with the resident and the form noted, 1. Level of care review: b. Long-term care. On 2/4/26, during a conversation with the owner of the facility where R2 discharged to, the owner reported the facility offered apartments and rooms . independent living. The owner went on to report that they provided no assistance with daily care, no medication administration and only provided reminders for medication and some meal prep if requested. The owner indicated they are not licensed by any regulatory agency as any type of medical facility. On 2/5/26at 11:52 AM, an interview was conducted with the facility's social worker (SW). The SW reported, He [R2] was a long-term resident here for a while, he did discharge from facility per his request. The lady had come here and was touring, he met the owner. He was eager to discharge, he has been here a while, I went over it with him and made sure transport to dialysis was set to continue and the owner was aware. The SW was asked to provide evidence of any discharge planning that took place for R2. On 2/5/26 at 12:05 PM, an interview was conducted with the nurse practitioner (NP), who was R2's medical provider. The NP reported that R2 was a dialysis patient and discharge was delayed due to setting up transport to and from dialysis. The NP went on to report that R2 went to a group home that she described as a little nursing home, staffed by certified nursing assistants (CNAs) and nurses. When the NP was made aware that R2 was discharged to an independent living setting she stated she was not aware and felt R2 needed a group home. On 2/5/26 at 12:30 PM, an interview was conducted with LPN #1, who was the unit manager. The unit manager was aware that R2 required assistance with ADLs and was under the impression that R2 discharged to a group home with 24-hour care. On 2/6/26 at 8:35 AM, an interview was conducted with the Director of Social Services (DSS). When asked about discharge planning and care planning, the DSS stated that discharge planning was a responsibility of the social work department and should be documented within the clinical record. On 2/6/26 at approximately 9:30 AM, the survey team was provided with evidence that a hospital bed was set up for R2. There was no evidence of any other services or equipment being arranged for R2. On 2/6/26 at approximately 10 AM, the facility administrator was made aware of the above findings. No further information was provided prior to conclusion of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of three residents in the survey sample (Residents #1 and #2) and failed to ensure the interdisciplinary team conducted quarterly care plan reviews for one of three residents in the survey sample (Resident #1).The findings include: 1. Resident #1's care plan was not revised to include plans to discharge from the facility. Care plan review meetings for R1 were not conducted at the time of quarterly MDS assessments. Resident #1 (R1) was admitted to the facility with diagnoses that included muscle wasting/atrophy, diabetes, magnesium deficiency, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, insomnia, affective mood disorder, atherosclerotic heart disease, cerebral infarction and vitamin deficiency. The minimum data set (MDS) dated [DATE] assessed R1 with moderately impaired cognitive skills. R1's clinical record documented the resident was discharged to a group home on 9/30/25. R1's plan of care (revised 4/22/25) documented the resident desired to remain in the facility. The care plan goals included, I will remain long-term care at this facility . Interventions regarding discharge status included, Social worker and Care Navigation will meet quarterly and as needed regarding patients wishes to remain long-term care. If my wishes change at any point I will inform the social worker . (sic) R1's plan of care was not revised to include problems, goals and/or interventions regarding discharge to the community. R1's clinical record documented the last care plan meeting conducted by the interdisciplinary team was on 1/21/25. Quarterly MDS assessments were documented on 4/18/25 and 7/19/25. The clinical record documented no care plan review meetings were conducted at the time of quarterly MDS assessments dated 4/18/25 and 7/19/25. On 2/5/26 at 8:40 a.m., the assistant administrator and social worker (other staff #3) responsible for discharge planning and scheduling care plan meetings were interviewed. The social worker stated she was responsible for updating care plans regarding discharge plans or changes in discharge status. The assistant administrator stated she reviewed the medical record and found no record of a care plan review meeting for R1 since 1/21/25. The social worker stated care plan review meetings were conducted quarterly around the time of the MDS assessments. The social worker stated she found no record of care plan review meetings for R1 since January 2025. The social worker provided no explanation of why R1 did not have care plan meetings in April 2025 or July 2025. On 2/5/26 at 9:45 a.m., the assistant director of nursing (ADON) was interviewed about care plan meetings and revisions. The ADON stated the social worker was responsible for scheduling and sending invitations for care plan meetings. The ADON stated care plan review meetings were conducted quarterly around the time of the required MDS assessments and that care plans were revised based on assessments and results of the meeting/review. The ADON stated discharge plans were part of the care plan and were expected to be revised if changes in discharge status occurred. The ADON stated plans for discharge were discussed in weekly risk meetings. The ADON stated care plan meetings were supposed to be conducted for each resident on a quarterly basis and that plans were revised as needs, status or conditions changed. The director of nursing (DON) was on vacation and not available for interview during the survey. The facility's policy titled Care Planning - Interdisciplinary Team (revised March 2022) documented, .The interdisciplinary team is responsible for the development of resident care plans .Resident care plans are developed according to the timeframes and criteria established by .483.21 [long-term care regulation tag F657] . This finding was reviewed with the administrator, assistant administrator, assistant director of nursing and regional nurse consultant during a meeting on 2/6/25 at 10:05 a.m. with no further information presented prior to the end of the survey. 2. For Resident #2 (R2), who discharged to an independent living, the facility staff failed to review and revise the care plan to include the discharge planning and discharge location. On 2/5/26 at 10:40 AM, a closed record review was conducted of R2's clinical record. According to the census tab, R2 resided at the facility 04/15/22-10/31/25. According to R2's diagnosis listing, the resident's diagnosis included, but were not limited to: Non-ST Elevation (NSTEMI) Myocardial Infarction [heart attack], hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, type 2 diabetes mellitus with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, other abnormalities of gait and mobility, and hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. According to the Discharge Summary dated 10/31/25, from the medical provider (nurse practitioner) it read in part, . He was seeing this afternoon after dialysis. He reports that he's having increased queasiness after dialysis, but he states that it is not nausea and he does not need any medication to manage his symptoms .Patient is stable for discharge to group home with home health PT OT [physical therapy and occupational therapy] Condition at discharge stable. According to R2's care plan a focus area initiated 7/25/24, which remained active until R2's discharge, read, [R2's name redacted] wishes to remain long-term care at this facility. Within R2's clinical record, there was not documented evidence of any discharge planning to include medication administration, medication education or training, management of the dialysis access site, medical equipment needs, home health being arranged as per physician orders/documentation, etc. The only notation was an entry by the social worker dated 8/28/25 that read, Writer received notice, resident is interested in discharging to a group home. Resident met with group home representative. UM aware, referral paperwork in reviewal. No discharge date in place. The next entry by the social worker was dated 9/29/25 that read, Resident discharge postponed to 10/31. On 2/4/26, during a conversation with the owner of the facility where R2 discharged to, the owner reported the facility was independent living On 2/5/26at 11:52 AM, an interview was conducted with the facility's social worker (SW). The SW reported, He [R2] was a long-term resident here for a while, he did discharge from facility per his request. The lady had come here and was touring, he met the owner. He was eager to discharge, he has been here a while, I went over it with him and made sure transport to dialysis was set to continue and the owner was aware. On 2/5/26 at 12:05 PM, an interview was conducted with the nurse practitioner (NP), who was R2's medical provider. The NP reported that R2 was a dialysis patient and discharge was delayed due to setting up transport to and from dialysis. The NP went on to report that R2 went to a group home that she described as a little nursing home, staffed by certified nursing assistants (CNAs) and nurses. When the NP was made aware that R2 was discharged to an independent living setting she stated she was not aware and felt R2 needed a group home. On 2/5/26 at 12:30 PM, an interview was conducted with LPN #1, who was the unit manager. The unit manager was asked if care plan meetings to discuss discharge planning for R2 were held and the unit manager said, I don't recall a care plan meeting for him. I can't say. On 2/6/26 at 8:35 AM, an interview was conducted with the Director of Social Services (DSS). When asked about discharge planning and care planning, the DSS said, Discharge planning starts on admission. Care plans are held quarterly. When asked if the plan or goals change, the SSD said that would be noted on the care plan. On 2/6/26 at approximately 10 AM, the facility administrator was made aware of the above findings. No further information was provided prior to conclusion of the survey.

Based on resident representative interview, staff interview, facility document review and clinical record review, the facility staff failed to provide written notice to the resident's legal guardian of discharge to the community and failed to accurately document medication reconciliation prior to discharge for one of three residents in the survey sample (Resident #1).The findings include:Facility staff failed to provide written notice to Resident #1's court-appointed legal guardian prior to or at the time of the resident's discharge to the community on 9/30/25. The clinical record documented no rationale for the resident's discharge to a lower level of care. Resident #1's discharge summary did not document all medications the resident was to continue after discharge.Resident #1 (R1) was admitted to the facility with diagnoses that included muscle wasting/atrophy, diabetes, magnesium deficiency, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, insomnia, affective mood disorder, compulsive sexual behaviors, atherosclerotic heart disease, cerebral infarction and vitamin deficiency. The minimum data set (MDS) dated [DATE] assessed R1 with moderately impaired cognitive skills and as requiring set-up/touch assistance for eating, dressing, hygiene and ambulation along with occasional incontinent of bowel/bladder. Section Q. of this MDS documented that the resident did not want to be asked about returning to the community on this or any other MDS assessments. R1 had resided in the nursing facility for over 3.5 years at the time of discharge on [DATE]. The clinical record documented R1 was adjudicated incapacitated and included a court order dated 2/23/22 for the appointed guardian to make all decisions for R1, including living arrangements, placements and finances on an indefinite basis.R1's clinical record documented the resident discharged to a group home on 9/30/25. The clinical record documented no involvement or consent from the legal guardian regarding the discharge. R1's clinical record included no documented basis for the discharge from a physician or provider. The clinical record documented comments from the resident about discharging to a group home, but included no discharge plan, rationale for the discharge and no documented request from the resident or the legal guardian about a desire to leave the nursing facility. It was unclear from the clinical record what prompted R1's discharge to the community. A social services note dated 9/26/25 documented, .Writer discussed resident discharge with resident and Group Home .Resident set to discharge to .Group home on 9/29. A note dated 9/29/25 documented the discharge was postponed to 9/30/25. There was no documented notification to the resident's legal guardian about the discharge.R1's Discharge summary dated [DATE] listed the resident's discharge destination as a Group Home with a street address and apartment number listed. The guardian's name and phone number were listed on the form but there was no documentation the guardian was notified of the discharge or provided written notice prior to the discharge. The discharge summary documented that pre and post discharge medications had been reconciled. The resident's Discharge summary dated [DATE] did not include all the resident's discharge medications. The resident's medication list on the discharge summary did not include aspirin, atorvastatin, ferrous sulfate, spironolactone and Trulicity. The NP listed in a 9/29/25 note, that these medications were among those to continue after discharge for treatment of cerebral infarction, hyperlipidemia, vitamin deficiency, congestive heart failure and diabetes. It was unclear from the discharge summary if the resident, resident's representative or the subsequent medical provider were issued copies of the discharge instructions.A social services note dated 10/7/25 documented R1's guardian had called concerning the resident's discharge and clarification of contact numbers. This note documented, .Writer informed [R'1 legal guardian] to feel free to reach out regarding resident .On 2/4/26 at 1:40 p.m., R1's legal guardian (other staff #1) was interviewed about the resident's discharge on [DATE]. The guardian stated she was not aware of the resident's discharge until a local hospital social worker (SW) called on 10/6/25 and reported that the resident had been found on the street with his belongings and was brought to the emergency department by authorities. The guardian stated the hospital SW told her the resident had been living in a group home. The guardian stated she had no idea that R1 was living in the community and had not been notified or consulted about the discharge. The guardian stated she talked with the facility's social worker (other staff #3) on 10/7/25 after the hospital notified her of the resident's status in the community. The guardian stated the facility social worker (other staff #3) claimed she had reached out to discuss the discharge plan. The guardian stated she never received a call or message from the facility's social worker and that she had talked with no one from the facility regarding R1 discharging from the facility. The guardian stated the resident should never have been discharged without her consent or input in the discharge plan/destination. The guardian stated she received no written notice of the resident's discharge and was not aware of the discharge or location of discharge until contact by the hospital social worker. The guardian stated, I was never contacted . On 2/4/26 at 2:10 p.m., the facility's SW (other staff #3) and the regional SW (other staff #4) were interviewed about R1's discharge on [DATE]. The SW stated she spoke to the legal guardian and then stated she did not speak directly to the legal guardian but that she had left a message with someone at a desk, asking the guardian to call her. The SW stated again she contacted the legal guardian multiple times but did not know how many times or when. The social worker provided no evidence that the guardian was contacted or that a written notice was sent to the guardian about the discharge.On 2/4/26 at 3:10 p.m., the facility's SW (other staff #3) and the regional SW (other staff #4) were interviewed again about R1's discharge location. When asked again about notification to the resident's legal guardian, the SW stated she called the guardian on 9/29/25 telling her of the discharge then stated it was late and that she had left a voice message. The SW stated the guardian did not call her until 10/7/25. The SW stated prior to 9/29/25, she had talked with someone at the desk, asking the guardian to contact her but that no one ever called her back. The SW provided no evidence of written notification to R1's guardian regarding the resident's discharge.On 2/4/26 at 3:45 p.m., the administrator was interviewed about concerns regarding R1's discharge on [DATE]. The administrator stated R1's legal guardian should have been involved prior to the resident's discharge and that there should have been agreement/consent from the legal guardian about the discharge plans.On 2/5/26 at 8:40 a.m., the facility SW (other staff #3) and the assistant administrator (administration #2) were interviewed again about R1's discharge. The assistant administrator stated there was only a discharge summary and no documented discharge plan or notifications regarding the discharge. The SW stated there was no written letter sent to the resident or the guardian about the discharge. On 2/5/26 at 11:55 a.m., the licensed practical nurse unit manager (LPN #1) that routinely cared for R1 was interviewed. LPN #1 stated she did not know what prompted R1's discharge and that discharge planning was handled by social services. LPN #1 stated all the resident's required medications should have been listed on the discharge summary. There was no evidence written notice was provided to R1's legal guardian prior to the resident's discharge on [DATE] that included reasons for the discharge, anticipated discharge date or destination location.The facility's policy titled Transfer or Discharge (revised March 2025) documented, .Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record .When the facility transfers or discharges a resident, information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider . This finding was reviewed with the administrator, assistant administrator, assistant director of nursing and regional nurse consultant during a meeting on 2/6/25 at 10:05 a.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor residents to prevent unnecessary medication administration for two of 61 residents in the survey sample, Residents #317, and #118. The findings include: 1. For Resident #317 (R317), the facility staff failed to monitor the resident's blood pressure for the administration of the medication Midodrine (used to treat low blood pressure) on multiple dates in July 2024. A review of R317's clinical record revealed a physician's order dated 7/17/24 for Midodrine 10mg (milligrams)-one tablet by mouth every eight hours. Hold for systolic blood pressure greater than 140. The medication was scheduled for 6:00 a.m., 2:00 p.m., and 10:00 p.m. Further review of R317's clinical record (including the July 2024 medication administration record, July 2024 blood pressure summary, and July 2024 nurses' notes) failed to reveal the resident's blood pressure was obtained prior to Midodrine administration on the following dates: -7/19/24 for the 2:00 p.m. and 10:00 p.m. doses -7/20/24 for the 2:00 p.m. dose -7/21/24 for the 2:00 p.m. dose -7/23/24 for the 2:00 p.m. dose -7/26/24 for the 2:00 p.m. dose -7/29/24 for the 6:00 a.m. dose -7/30/24 for the 2:00 p.m. dose On 6/12/25 at 10:24 a.m., R317's Midodrine order was reviewed with RN (registered nurse) #1. RN #1 stated the resident's blood pressure should have been checked right before every time Midodrine was administered, so the nurses knew if the resident's blood pressure was within parameters and if the medication could be given. On 6/12/25 at 3:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Administering Medications documented, 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary . No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for one of 61 residents in the survey sample, Resident #317. The findings include: For Resident #317 (R317), the facility staff failed to attempt non-pharmacological interventions prior to the administration of PRN (as needed) tramadol (pain medication) on multiple dates in July 2024 and August 2024. A review of R317's clinical record revealed a physician's order dated 7/9/24 for tramadol 50mg (milligrams)-one tablet every six hours as needed for pain. A review of R317's July 2024 and August 2024 MARs (medication administration records) revealed the resident was administered PRN tramadol on 7/13/24, 7/17/24, 7/25/24, and 8/2/24. Further review of R317's clinical record (including the July 2024 and August 2024 MARs and nurses' notes) failed to reveal non-pharmacological interventions were offered/attempted prior to the administration of PRN tramadol on the above dates. On 6/12/25 at 10:24 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated non-pharmaceutical interventions such as touch, relaxation, exercise, or music should be attempted prior to the administration of as needed pain medication, and this should be documented in a nurse's note. On 6/12/25 at 3:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Pain Assessment and Management documented, 2. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: a. environmental - adjusting the room temperature, smoothing the linens, providing a pressure reducing mattress, repositioning, etc.; b. physical - ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture, etc.; c. exercise - range of motion exercises to prevent muscle stiffness and contractures; and d. cognitive or behavioral - relaxation, music, diversions, activities, etc. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to promote resident's dignity for two of 61 current residents in the survey sample, Residents #113 (R113) and R115. The findings include: 1. For R113, facility staff failed to allow person items to be placed on a shelf in front in the window of the resident's room. R113 was admitted to the facility with diagnosis that included but was not limited to major depressive disorder (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/02/2025, R113 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R113 was cognitively intact for making daily decisions. On 06/11/25 at approximately 7:51 a.m. an interview was conducted with R113. R113 stated that she was told by a staff member that she was not allowed to have anything sitting on a shelf, above the PTAC (packaged terminal air conditioner) unit (self-contained heating and air conditioning system mounted through a wall), in front of the window in R113's room. R113 stated she had to remove some bottles of water and a stuff animal. On 06/11/2025 at approximately 9:05 a.m. an interview and observation of R113's room was conducted with OSM (other staff member) #1, director of maintenance. After observing the PTAC unit and shelf over the top of the unit he stated that the shelf was connected to the wall and that there was no reason why R113 could place anything in the window. When asked if the items would be resting on the PTAC unit he stated no. On 06/11/2025 at approximately 9:33 p.m. an interview was conducted with CNA (certified nursing assistant) #2. When asked about residents being allowed to place personal items in their room windows she stated that residents were not allowed because it was a safety hazard. On 06/11/2026 at approximately 2:20 p.m. an interview was conducted with LPN (licensed practical nurse) #2. When asked about residents being allowed to place personal items in their room windows she stated that residents were not allowed because it was a fire hazard. On 06/11/2025 at approximately 13:05 p.m. an interview was conducted with ASM (administrative staff member) #4, regional director of clinical services, regarding resident's placing personal items in their room windows. She stated that it was not a fire hazard, and residents were allowed to place items in their windows. When asked it was dignified to prevent a resident from displaying personal item in their room window she stated no. The facility's policy Resident Rights documented in part, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: b. be treated with respect, kindness, and dignity. On 06/11/2025 at approximately 4:40 p.m., ASM #1, administrator, ASM #2, director of nursing, ASM #3 assistant administrator, ASM #4, regional director of clinical services, and ASM #5, regional vice president, were made aware of the above findings. No further information was provided prior to exit. References: (1) It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm. 2. For R115, facility staff failed to provide a meal in a timely manner. R115 was admitted to the facility with diagnoses that included but were not limited to swallowing difficulties and a stroke. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/07/2025, R115 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R115 was cognitively intact for making daily decisions. The comprehensive care plan for R115 dated 11/26/2024 documented in part, I have an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) impaired mobility .Requires total care from staff for ADLs. On 06/10/25 at approximately 2:40 p.m. an observation revealed R115's lunch tray sitting on his over-the-bed table. R115 he stated that he had not eaten lunch and that he had been waiting to receive assistance with eating. At approximately 2:42 p.m. a CNA (certified nursing assistant) was observed entering R115's room and began to feed him. On 06/10/25 at approximately 2:54 p.m. an interview was conducted with LPN (licensed practical nurse) #1. When asked what time the lunch trays arrived on the unit on 06/10/2025, she stated they arrives at 1:30 p.m. On 06/11/2025 at approximately 1:55 p.m. an interview was conducted with LPN #2, unit manager. When asked to describe the procedure for passing out meal trays and assisting residents with eating she stated that when the meal trays arrive on the unit, all the trays are passed out to all the residents except those who are unable to feed themselves. The meal trays for the residents who require assistance with eating are left on the tray carts to stay warm. She when all the trays are passed out the CNAs (certified nursing assistants) get the meals from the cart for the residents requiring assistance and assist the residents on the CNAs assignment. When asked if it was dignified that a resident should wait over an hour to receive assistance to eat she stated no. When asked if she knew which CNA was assigned to feed lunch to R115 on 06/10/2025 she stated it was (Name of CNA #1). On 06/11/2025 at approximately 1:55 p.m. an interview was conducted with CNA #1. When asked if she was assigned to feed R115 on 06/10/2025 during lunch she stated yes. When informed of the observation described above she stated that she was caught up conducting resident care before the lunch trays arrived on the floor. CNA #1 stated that the care took longer than she expected and when she finished she went to the food cart and R115's lunch tray was not there and assumed someone else feed R115. When asked if it was dignified that a resident should wait over an hour to receive assistance to eat she stated no. On 06/11/2025 at approximately 4:40 p.m., ASM #1, administrator, ASM #2, director of nursing, ASM #3 assistant administrator, ASM #4, regional director of clinical services, and ASM #5, regional vice president, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to honor a resident's food preferences/dislikes for one of 61 residents in the survey sample, Resident #14. The findings include: For Resident #14 (R14), the facility staff failed to honor the resident's dislike for grits. R14's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/1/25 documented the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 9/11/25 at 9:46 a.m., R14's breakfast tray was observed. R14's meal ticket documented the resident disliked grits. A bowl of grits was observed on R14's breakfast tray. R14 stated she receives food that she dislikes almost every day. On 6/12/25 at 8:42 a.m., an interview was conducted with OSM (other staff member) #10, the dietary district manager. OSM #10 stated that upon admission, the dietary staff talks to residents and obtains a list of their dislikes. OSM #10 stated the dietary staff enters this list into the computerized meal tracker system then during meal service, the meal tracker system identifies the resident's dislikes and generates an alternative food item that is printed on the meal ticket to be served. OSM #10 stated the dietary staff are supposed to follow the printed meal ticket when preparing residents' meal trays. On 6/12/25 at 3:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Food Preferences documented, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide a comfortable and homelike environment for one of 61 residents in the survey sample, Resident #85. The findings include: For Resident #85 (R85) (a resident who resided on the third floor), the facility staff failed to provide enough linens for resident care. R85's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/29/25 documented the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 6/11/25 at 3:44 p.m., an interview was conducted with R85. The resident voiced concern that there were not enough linens for resident care. On 6/11/25 at 3:47 p.m., an interview was conducted with LPN (licensed practical nurse) #1 and CNA (certified nursing assistant) #12. CNA #12 stated a laundry aide delivers a linen cart for the 3:00 p.m. to 11:00 p.m. shift at approximately 3:15 p.m. and usually there is not enough linens for resident care. CNA #12 stated the nursing staff do not have access to the laundry room to obtain more linens and the laundry aide becomes, fussy if staff ask for more linens. LPN #1 stated a lack of linens on the unit usually occurs every day. A resident census report documented 68 residents resided on the third floor on 6/11/25. A linen delivery schedule dated 6/11/25 revealed the following linens were delivered to the third floor for the 3:00 p.m. to 11:00 p.m. shift: - 20 flat sheets -20 fitted sheets -10 pillowcases -30 towels -50 wash cloths -10 gowns -10 pads -5 blankets -5 bedspreads On 6/11/25 at 3:53 p.m., an observation of the designated third floor 3:00 p.m. to 11:00 p.m. linen cart (the only linen cart on the floor, located in the clean linen room) was conducted. The following was observed: - 29 washcloths - 10 gowns - 8 pillowcases - 13 towels - 12 fitted sheets - 4 pads - 8 fitted sheets - 7 bath blankets - 2 bed spreads On 6/11/25 at 5:03 p.m., an interview was conducted with OSM (other staff member) #7 (the environmental service district manager). OSM #7 stated linen aides take a linen cart to each floor in the morning, at 3:00 p.m., and then leave an extra cart for the 11:00 p.m. to 7:00 a.m. shift. OSM #7 stated extra linens are kept in the laundry room and the linen aides and receptionist have a key to the laundry room. (Note- linen aides were not scheduled for the entire 3:00 p.m.-11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts, and during an interview with the administrator on 6/11/25 at 5:15 p.m., the administrator stated the receptionist did not have a key to the laundry room). On 6/11/25 at 5:17 p.m., an interview was conducted with OSM #8 (a laundry aide who works part of the 3:00 p.m. to 11:00 p.m. shift). OSM #8 stated she has been a laundry aide for so long that she knows how to delegate how much linens should go on each cart but sometimes at the end of the month, she has to use her imagination because by then, the facility has to order more linens. OSM #8 stated she has to lock the door to the laundry room when she is not in there because staff will come in and take too many linens. OSM #8 stated no one has access to the laundry room after she leaves at 10:00 p.m. OSM #8 stated that when nursing staff requests extra linens, she may not have what they request because she is in the process of washing and drying linens, but she gives them what she can. On 6/12/25 at 11:04 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated there usually is not enough linens to care for residents. On 6/12/25 at 11:39 a.m., an interview was conducted with CNA #9. CNA #9 stated some days there are enough linens on the cart and some days there are not enough linens on the cart. CNA #9 stated sometimes they have to wait for the laundry aides to wash and dry the linens and replenish the carts. On 6/12/25 at 3:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Homelike Environment documented, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: e. clean bed and bath linens that are in good condition .

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to develop and implement comprehensive resident centered care plan for 1 Resident (#5) in a survey sample of 5 Residents. The findings included: For Resident # 5 the facility staff failed to develop and implement a care plan that included interventions for preventing pressure ulcers. Resident #5 was admitted to the facility on 10/3 with diagnoses including but not limited to cerebral infarction due to unspecified cerebral artery, altered mental status, hypertension, gastro-esophageal reflux, hyperlipidemia, dementia, mood disturbance, anxiety degenerative disease of the nervous system, Type 2 diabetes, muscle wasting and atrophy cognitive communication deficit anemia and vitamin d deficiency. On 11/4/24 a review of the clinical record revealed that Resident #5 had mushy left heel noted during admission assessment and documented in the progress notes. No md notification or treatment orders were documented. On 11/4/24 the following observations were made: 11:20 p.m. - Resident in bed supine position, heels on bed, spouse at bedside. 12:00 pm Resident sitting up 45-degree angle in bed spouse at bedside assisting Resident with eating lunch. Resident dressed in hospital gown with long sleeved shirt under gown. 1:35 p.m. - Resident lying in bed eyes closed resting. Resident in hospital gown with long sleeved shirt underneath, lying in supine position heels on mattress. 3:00 p.m. - Resident in bed lying in supine position, heels on mattress, Resident is being moved to room [ROOM NUMBER]. 3:45 p.m. - Resident in new room lying in bed supine position still dressed in hospital gown, heels in contact with mattress. 3:55 p.m. - Asked LPN B (Licensed Practical Nurse) if she would look at Resident #5's skin with me and she stated that she would. Resident #5 had no open areas to the skin at this time. LPN B was asked if a Resident was noted in the documentation to have mushy left heel what if anything should be done, and she responded that the heels should be floated. When asked if that was all she stated that they should probably let the physician know. On 11/6/24 a review of the care plan read: FOCUS: I have impaired skin integrity r/t [Area left blank] Date Initiated: 10/28/2024 GOAL: will be at reduced risk for new or worsened impaired skin integrity daily through the review date. Date Initiated: 10/28/2024 Target Date: 01/21/2025 INTERVENTIONS: Administer treatments as ordered and monitor effectiveness. Date Initiated: 10/28/2024 Evaluate for the presence of pain and administer pain medication as ordered to promote my comfort. Monitor for side effects and effectiveness. Date Initiated: 10/28/2024 Monitor for new or worsening s/sx of complications and infection: necrosis, erythema, warmth, edema, exudate, foul odor, maceration, pain/tenderness, fever/chills, etc. Report to physician if noted and follow-up as indicated. Date Initiated: 10/28/2024 Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. Date Initiated: 10/28/2024. On the afternoon of 11/6/24 an interview was conducted with the DON (Director of Nursing) who was asked what the expectation is if a mushy left heel is identified and documented on admission, and she stated that she would expect the nurse to notify the physician to seek out any orders and implement nursing measures that do not require orders such as floating heels on a pillow. When asked about the expectation of staff turning and repositioning patients, she stated that it should be done every 2 hours or more as needed or desired by the Resident to prevent breakdown. On 11/6/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to review and revise the care plan care plan for 1 Resident (#5) in a survey sample of 5 Residents. The findings included: For Resident # 5 the facility staff failed to revise the care plan after the Resident had an actual fall. Resident #5 was admitted to the facility on 10/3 with diagnoses including but not limited to cerebral infarction due to unspecified cerebral artery, altered mental status, hypertension, gastro-esophageal reflux, hyperlipidemia, dementia, mood disturbance, anxiety degenerative disease of the nervous system, Type 2 diabetes, muscle wasting and atrophy cognitive communication deficit anemia and vitamin d deficiency. On the morning of 11/6/24 a review of the progress notes revealed the following note: 11/5/24 10:50 a.m. - Nursing observations, evaluation, and recommendations are Resident was observed on the floor by social worker on left side of her bed in sitting position. Nursing staff was notified. When interview resident she stated she was trying to go to out. Resident has poor vision with glasses. Skin warm dry and intact. Patient is incontinent of bowel and bladder. Note she had a large BM. PROM x 4 extremities. an unwitnessed fall in her room. Assisted off the floor x 2 staff. No physical injuries noted. Neuro checks initiated. Husband at bedside and is aware. On 11/5/24 a review of the care plan revealed the following: FOCUS: I am at risk for falls r/t confusion., deconditioning/ weakness., gait/ balance problems., poor safety awareness. Date Initiated: 10/28/2024 GOAL: will be free of fall related injury through the next review date. Date Initiated: 10/28/2024 Target Date: 01/21/2025. INTERVENTIONS: Assist and/ or remind me to change position and get up from sitting or lying slowly due to orthostatic blood pressure problems (dizziness/fainting with position changes). Date Initiated: 10/28/2024 Be sure call light is within reach and provide reminders to use call for assistance as needed. Date Initiated: 10/28/2024 Create a safe environment; floors clear of clutter, clean up spills, adequate lighting. Date Initiated: 10/28/2024 Educate resident, involved family members, and caregivers about safety reminders, fall prevention, and what to do if a fall occurs. Date Initiated: 10/28/2024 Encourage adequate meal and fluid intake to help prevent hyper/hypoglycemic episodes and dehydration. Date Initiated: 10/28/2024 Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date Initiated: 10/28/2024 Encourage resident to participate in activities that minimize the risk for falls while providing diversion and distraction. Date Initiated: 10/28/2024 Ensure that resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Preferably rubber, non-slip soles or gripper socks. Date Initiated: 10/28/2024 Keep personal items and frequently used items within reach. Date Initiated: 10/28/2024. On 11/6/24 at 3:40 p.m. an interview was conducted with the DON who was asked what should happen after a fall and she stated the care plan should be updated to state the Resident had an actual fall and include new interventions to prevent future falls. When asked if this was done, she stated that it was not. On 11/6/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to maintain a safe environment for one dependent resident (Resident #4) in a survey sample of 6 residents. For Resident # 4, the facility staff failed to prevent a fall from the bed during incontinence care on 11/26/2023. Findings included: Resident #4 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Epilepsy, Parkinsonism, and Essential Hypertension, The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 11/9/2023. The MDS coded Resident # 4 with a BIMS (Brief Interview for Mental Status)score of 4/15 indicating severe cognitive impairment; the resident required assistance with activities of daily living and bathing and always incontinent of bowel and bladder. Review of the closed electronic clinical record was conducted on 11/4/2024 to 11/6/2024. Review of the Progress Notes revealed documentation of a Nursing note on 11/26/2023 at 8:29 p.m. regarding a fall. The note stated the resident was laying on the left side while receiving ADL (Activities of Daily Living) care and fell out of the bed when the aid walked to the sink to get fresh water. The note also stated the resident was assessed, neuro (neurochecks) started, RP (Responsible Party made [sic], MD (Medical Doctor) notified. Per MD we can notify hospice of fall in person in the morning. Further review revealed no documentation of any injury sustained during the fall. Resident # 4 was discharged to home the next day on 11/27/2023 with Hospice care. On 11/6/2024 at 11:45 a.m., an interview was conducted with the Director of Nursing who stated CNA-B was no longer employed at the facility. She also stated that LPN (Licensed Practical Nurse)-C was also no longer employed at the facility. On 11/6/2024 at 1:15 PM an interview was conducted with the Director of Nursing who stated her expectation was for the staff to provide incontinence care in a safe manner. The Director of Nursing stated that the Certified Nursing Assistant was expected to provide incontinence care and to use a basin, If you have to leave the bedside, they should secure the resident ' s position prior to leaving the resident The Director of Nursing provided copies of education provided to the staff after Resident # 4 fell. The Director of Nursing stated the staff were expected to keep residents safe. On 11/6/2024 at 2:10 p.m., an interview was conducted with the Human Resources Director who gave the termination dates: CNA-B 02/21/2024 and LPN-C terminated employment on 03/08/2024. On 11/6/2024 at 3:05 p.m.,an interview was conducted CNA (Certified Nursing Assistant)-B who stated the expectation was that a resident should be returned to a safe position prior to the staff leaving the bedside. CNA-B stated staff members were expected to keep the residents safe. Review of the Fall report and investigation revealed a Witness Statement revealed the following excerpt from the statement: The CNA noticed that the patient in room _____ (redacted) was lying on her back. The CNA proceeded to set up to change the patient, using wash cloth, towels, soap and warm water. The CNA proceeded to turn the patient on her right side facing the door, with her right leg in front of her left leg, The CNA did make an attempt to pull her legs back onto the bed. The CNA proceeded to walk over toward the sink to wet the warm wash cloths. The patient fell forward onto the floor. The nurses assested [sic] the patient. Review of the care plan revealed that Resident #4 required assistance with Activities of Daily Living. During the end of day debriefing on 11/6/2024, the Administrator, Director of Nursing and Assistant [NAME] President of Operations were informed of the findings that the Certified Nursing Assistant failed to keep the resident safe during the provision of ADL care. No further information was provided.

Based on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure freedom from abuse and neglect for one resident (Resident #1) in a survey sample of 8 residents. The findings included: For Resident #1, the facility staff failed to ensure the resident was not sexually abused by a Certified Nursing Assistant (CNA)-B who was assigned to provide care for the resident's needs, and failed to report an allegation of abuse to the administrator timely. Resident #1 was admitted to the facility on with diagnoses that included but were not limited to: quadriplegia, C5-C7 (cervical spine 5-7) incomplete and dysthymic disorder. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 01/22/2024. The MDS coded Resident #1 with a BIMS (Brief Interview for Mental Status) score of 14 (of a possible 15 points) which indicated no cognitive impairment. Resident #1 required extensive assistance of staff persons with ADLs (activities of daily living). Review of the electronic clinical record was conducted throughout the survey. On 2/22/2024 at 2:28 p.m., an interview was conducted with the Administrator and Director of Nursing regarding a facility synopsis of events of alleged sexual abuse that occurred on 1/8/2024. They were asked if the facility staff members including Certified Nursing Assistants should be able to identify and report abuse and neglect. The Administrator stated that all the staff should be able to identify and report abuse and neglect. When asked if the sexual abuse allegation that occurred on 1/7/2024 was investigated, the Administrator stated it had not been investigated until it was reported the day after the incident occurred. When asked if this was reported to the appropriate offices, the Administrator stated Yes, it was investigated immediately once we were informed. Review of the facility investigation revealed the statements that Resident #1 did complain of taking pain medication, falling asleep and later waking up to Certified Nursing Assistant-B performing oral sex on him. On 2/24/2024 at 1:10 p.m., an interview was conducted with Resident #1 who was alert and oriented. Resident #1 stated he took his pain medication around 9 or 9:15 a.m. He stated Narcotics usually make me sleepy. He stated he was awake when CNA-B came in to assist with his bath. Resident # 1 stated CNA-B washed my top and asked are you comfortable. Resident #1 stated he went to sleep or napped and felt something crazy; his mouth was coming off my penis. Resident #1 stated he yelled and CNA-B told him No, please be quiet. Resident #1 stated CNA-B told him, I'm sorry, I will give you anything. I am going to lose my job. Resident #1 stated CNA-B offered money, marijuana plants or anything. Resident #1 stated he went through a mental shock. Resident #1 stated he told another girl who worked there as a CNA (CNA-C). Resident #1 stated he went to high school with CNA-C and felt comfortable with her so he confided what happened with CNA-B. Resident #1 stated he told CNA-C not to tell anyone. Resident #1 stated the incident happened on a Sunday and he knew the administrative staff was not on duty. He stated he intended to tell the administrative staff on the next day, 1/8/2024. Resident #1 stated he did not understand why CNA-B did that to me He stated he never made suggestions to CNA-B that he wanted any type of sexual encounter. Resident #1 stated it was very upsetting. During the interview, Resident #1 stated he typically would fall asleep after taking pain medication. On 1/7/2024, he did fall asleep but woke up for some reason and when he opened his eyes, he saw CNA-B taking his mouth off of his penis. Resident # 1 stated he was very shocked and upset about this incident. Resident #1 stated he had not known CNA-B outside of the facility. Resident #1 stated he knew this incident did not make him less of a man but it bothered him that CNA-B chose to violate him. Resident #1 stated he asked CNA-C did not report the incident because he asked her not to say anything. Resident #1 stated CNA-C was terminated but he did not think CNA-C should have been terminated. Resident #1 stated that was not fair because he heard a rumor from another CNA that CNA-B had committed this same type of act on another resident in another facility. As a result of this incident, Resident #1 required the use of anti-anxiety medications and therapy visits with the psychologist. Resident #1 stated he could not understand why that man did this to me. Resident #1 stated it was then and still is upsetting. The facility's Administrator and Director of Nursing immediately implemented its abuse policies on 1/8/2024 when they were informed of the allegation of sexual abuse of a resident by a staff member (CNA-B) which occurred on 1/7/2024. All of the employees involved were suspended pending the investigation. CNA-B was terminated and CNA-C was terminated for not immediately reporting an allegation of sexual abuse and for having an inappropriate relationship with Resident #1. Review of documentation sent to the Virginia State Board of Health Professions revealed that CNA-B and CNA-C were reported to the Board of Health Professions. Review of the documentation revealed the following documentation about implementing the abuse policy. (Facility's name redacted) Past Non Compliance Request 1. Yes, we had deficient practice. 2. Yes, the deficient practice occurred after the last survey. 3. Yes, we have presented sufficient evidence that the deficient practice has been corrected. a. All staff members were immediately re-educated on abuse policy and the reporting of abuse. b. The facility immediately reported the incident to the state agency, state licensing board and police. c. Employees were immediately contacted for a statement, suspended and removed from the schedule. d. Resident was seen by his Primary Physician and Psych seeing patient to help his through this traumatic event. e. Weekly audits conducted along with ADHOC (when necessary or needed) QAPI (Quality Assurance Performance Improvement) and Monthly QAPI reporting. 4. Yes, we now are in substantial compliance, and the deficient practice has not occurred again. a. Residents are asked 3 xs (three times) a week the abuse questions to ensure compliance b. No resident has reported abuse. c. Residents acknowledge they know whom to report abuse to and that staff ask then about it. 5. Facility is in compliance as of 1/8/24. Interviews were conducted with a total of over twenty staff members from all departments to include Nursing, Housekeeping, Laundry, Dietary, Maintenance and Administrative staff. All were able to state signs and symptoms of abuse, prevention of abuse, reporting immediately and to whom to report, and protecting the resident. They stated they could not return to work until they had the abuse training. They stated they know to report any suspicious behavior by coworkers. During the 4 days of survey, there were no observations, evidence, nor complaints of abuse expressed by residents. There were no other residents identified as having had been abused by the CNA. No further information was provided. This deficiency is cited at harm at past non-compliance.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to meet professional standards of quality for three Residents (#3, #2, and #1) in a survey sample of 8 residents. Findings included: During tour of the facility on 2/22/2024, the nurses were asked the time of the next scheduled medication pass. The nurses stated 1:00 p.m., On the third floor, nurses were observed passing medications at 11:26 a.m. One nurse was observed standing at medication cart located at the nurses station. One nurse LPN (Licensed Practical Nurse)-F was observed pouring medications in medication cups and walking to a resident's room. The nurse returned to the nurses station, poured medications and walked to another resident's room. The nurse was observed repeating that with other residents. When asked if the medications she was administering was from the morning medication pass, LPN-F stated Yes. LPN-F stated she was handling something that happened earlier and was late passing the medications. Another nurse (LPN-H) was observed standing at another medication cart located at the nurses station. Review of the as worked schedule revealed there were several nurses working on the unit. There was no documentation presented to the surveyor about what happened earlier that prevented medications from being administered on time. Nor was there any information presented about whether any other nurses provided assistance to ensure medications were administered on time to the residents assigned to LPN-F. 1. For Resident # 3, the facility staff failed to follow professional standards regarding medication administration. Review of the January 2024 and February 2024 Medication Administration Records for Resident # 2 revealed documentation that numerous medications were not administered timely as ordered. There were numerous occasions when medications were administered late. Some medications were administered over 2 to 6 hours late. Interviews were conducted with seven licensed nurses who all stated that medications should be administered within one hour before and one hour after the time of scheduled administration. The nurses included but were not limited to: LPN (Licensed Practical Nurse)-B, LPN-D, LPN-E, LPN-F, LPN-G, LPN-H and LPN-J. Valid physicians orders were evident. The Director of Nursing stated the facility uses [NAME] as their nursing standard of practice. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. Reference: Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 2/26/2024 Review of the Facility's Policy on Administering Medications revealed the following excerpts, 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified for example, before and after meal orders. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. During the end of day debriefing on 2/27/2024, the facility Administrator, Director of Nursing were informed of the findings. No further information was provided. 2. For Resident #2, the facility staff failed to follow professional standards regarding medication administration. Review of the January 2024 and February 2024 Medication Administration Records for Resident # 2 revealed documentation that numerous medications were not administered timely as ordered. There were numerous occasions when medications were administered late. Interviews were conducted with seven licensed nurses who all stated that medications should be administered within one hour before and one hour after the time of scheduled administration. The nurses included but were not limited to: LPN (Licensed Practical Nurse)-B, LPN-D, LPN-E, LPN-F, LPN-G, LPN-H and LPN-J. Valid physicians orders were evident. On 2/26/2024 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings that medications were not administered timely. The Director of Nursing stated the expectations were that nurses should administer medications as ordered by the physician. The Director of Nursing also stated nurses should administer medications timely and document immediately after the administration of the medication. Review of the Facility's Policy on Administering Medications revealed the following excerpts, 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified for example, before and after meal orders. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. The Director of Nursing stated the facility uses [NAME] as their nursing standard of practice. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. Reference: Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 2/26/2024 During the end of day debriefing on 2/27/2024, the facility Administrator, Director of Nursing were informed of the findings. No further information was provided. 3. For Resident #1, the facility staff failed to follow professional standards regarding medication administration. Review of the January 2024 and February 2024 Medication Administration Records for Resident #1 revealed documentation that numerous medications were not administered timely as ordered. There were numerous occasions when medications were administered late. Interviews were conducted with six licensed nurses who all stated that medications should be administered within one hour before and one hour after the time of scheduled administration. The nurses included but were not limited to: LPN (Licensed Practical Nurse)-B, LPN-D, LPN-E, LPN-F, LPN-G, LPN-H and LPN-J. Valid physicians orders were evident. The Director of Nursing stated the facility uses [NAME] as their nursing standard of practice. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. Reference: Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 2/26/2024 Review of the Facility's Policy on Administering Medications revealed the following excerpts, 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified for example, before and after meal orders. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. During the end of day debriefing on 2/27/2024, the facility Administrator, Director of Nursing were informed of the findings. No further information was provided.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to provide a clean and comfortable environment on two of three floors and in the dining room Findings included: On the second and third floors, the shower rooms were observed to be in need of cleaning, affecting residents on those floors who use the shower rooms. During the initial tour of the facility on 2/22/2024, the dining room wall near the entrance of the kitchen was observed to be very dirty with pronounced brown colored streaks extending from the floor to approximately 4 feet up the wall. Residents were observed sitting at tables in the dining room eating meals. The residents had clear view of the dirty wall. The wall was observed to still be dirty on 2/23/2024 and 2/26/2024 during rounds. Residents were observed participating in activities while in the dining room at various times during the survey. On 2/26/2024, tour of the physical environment revealed other areas of concern. On 2/26/2024 at 11 a.m., an interview was conducted with an alert resident in the survey sample (Resident # 7) who stated the shower room on his floor was dirty. Resident #7 then stated he preferred to take a bath at the sink in his room instead of using the shower room. The Director of Nursing went with the surveyor to observe the condition of the shower room. The shower room had to be opened with a code entered by the facility staff. The room had a pungent odor and the commode was dirty with evidence of feces. There was no solid waste in the toilet bowl but stains of feces were evident. The Director of Nursing stated the room was not filthy but could use more cleaning. The Unit Manager stated the facility staff members had to enter a code to access the shower room. Residents could not enter the shower room without a staff member. The Unit Manager stated the facility's nursing staff should inform the Housekeeping department whenever the commode was noted to need cleaning. On 2/26/2024 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. They were also informed of the dirty wall in the dining room. On 2/27/2024 at 9:15 a.m., an interview was conducted with the Regional Housekeeping Manager who stated he wanted to discuss any findings related to housekeeping. The Regional Housekeeping Manager toured the dining room on the first floor and shower rooms on the second and third floors with the surveyor. The Regional Housekeeping Manager stated the wall in the dining room where trays were stored was soiled. There was evidence that the wall had been cleaned from the day before but there was still residue/stains noted on the wall. He stated the staff members must have spilled coffee in that area. He also stated the facility's staff members should let the Housekeeping Department know when and if spills happen. Tour of the second floor shower room revealed the stale, pungent odor. The Regional Housekeeping Manager stated he could understand why Resident #7 complained about the shower room. He stated there was no ventilation in the shower room. When asked if he or one of his loved ones would want to shower in that room, he replied Honestly, no. Tour of the third floor shower room revealed odors, but not quite as pungent as on the second floor. There was evidence of an orange-ish colored residue on the walls and baseboards on the right side of the shower room near the stretcher. The Regional Housekeeping Manager and Housekeeping Director stated they could smell the odor. The Regional Housekeeping Manager stated he did not know what the facility could do about the odor but thought there needed to be better ventilation in the shower room. During the end of day debriefing on 2/27/2024, the facility's Administrator and Director of Nursing were again informed of the findings. No further information was provided.

Based on observations, resident interview, staff interview, facility documentation review, the facility staff failed to ensure an effectively functioning call bell system on two of three units affecting two residents (Residents #3 and #6) in a survey sample of 8 residents. Findings included: 1. For Resident #2, the call bell system did not work properly and the facility staff implemented the use of a cow bell system for notification of the need for assistance. On 2/23/2024, a cow bell was observed in Resident #2's room. An interview was conducted with Resident #2 who stated the cow bell had been in his room for a long time. Resident #2 stated the cow bell was really noisy and disturbed others. On 2/26/2024 at 10:10 a.m., an interview was conducted with the [NAME] President of Maintenance who stated he could provide the documents regarding maintenance because the Maintenance Director was off. The [NAME] President of Maintenance stated the facility utilized the electronic documentation of service requests in the computer system. Review of the facility's documentation of the tests of the nurse call system from October 2023 to January 30, 2024 revealed the call system was tested each month on each floor. There were weekly tests for each month. All of the documentation showed that the call bell systems passed on each floor of the facility every week. The monthly reports were documented as 9/16/2023, 10/2/2023, 11/6/2023, 12/8/2023, 12/29/2023, and 1/20/2024. The reports showed that on October 2, 2023, test of the Nurse Call System showed all of the units passed, however there was a note that stated Did a (sic) audit on the call lights and bulb, found 2 that were missing bulbs on the first floor. There were no other statements documented regarding the call bell system. During the end of day debriefing on 2/26/2024, the facility Administrator and Director of Nursing were informed of the findings. 2. For Resident #6, the facility staff failed to ensure the call bell system was working properly. Resident #6's most recent MDS (minimum data set) assessment at the time of the incident was a Quarterly assessment with an ARD (Assessment Review Date) of 1/28/2024. The MDS coded Resident #6 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment. During rounds of the facility, Resident #6 complained that the call bell in her room did not work. She stated she waited for hours the previous night for the call bell to be answered. She stated the nursing staff members told her that her call bell was a ghost light because they could not see it lit up on the board at the nurses station and it did not light up outside her room. Resident #6 stated this did not happen often but she wanted it to be fixed. Resident #6 stated the facility staff member told her the problem existed in the bathroom of the adjoining room. She stated there was a certain way the call was pulled in the adjoining room and it affected the call bell in Resident # 6's room. The call light was turned on by the surveyor. The light on the inside of the room was illuminated. The light on top of the door did not illuminate. There were nursing staff members at the nurses station. The Director of Nursing went with the surveyor to the room to speak with Resident #6. The Director of Nursing checked the call bell at Resident #6's bedside and the call bell of the roommate. The Director of Nursing stated she would investigate the issue. Review of maintenance logs revealed monthly checks of the call light system. The Director of Nursing stated the Maintenance Department was expected to repair the call bell system as quickly as possible. The Director of Nursing also stated the expectation was for staff to investigate, make frequent rounds to determine where a light might be ringing if the audible sound could not be located. She also stated the staff should notify the Maintenance Department of any noted or reported issues with call bells. On 2/26/2024 at 10:10 a.m., an interview was conducted with the [NAME] President of Operations who stated the he would answer questions about the Maintenance of the call bell system because the Maintenance Director was not in the facility. The [NAME] President stated the facility had a process to routinely ensure the call system for residents was operational. The [NAME] President presented copies of the Maintenance Logs for six months including September 2023 to January 2024. During the 4 days of survey, there were observations of call bells not functioning properly. There were some call bells that did not have an audible sound at the nurse's station, One call bell in a room on the second floor was described as a Ghost light because the staff could hear the sound but could discern the location. On the last day of survey on 2/27/2024, the Administrator and the Director of Nursing made rounds with the surveyor on the first floor to check the call bell system. There were two rooms on the first floor that had call bells that did not illuminate when the call bell button was pressed. Those rooms had not been occupied at the beginning of survey but had recent admissions. During the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. The Director of Nursing stated the call bell in Resident #6's room was affected by the bathroom call bell in the adjoining room. The Director Nursing stated the Maintenance Director was informed of the issues. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to implement the abuse policy for one resident (Resident #1) in a survey sample of 8 residents. Findings included: For Resident #1, the facility staff failed to implement their abuse policy as evidenced by failure to report an allegation of sexual abuse by a Certified Nursing Assistant (CNA)-B. According to the facility's documentation, Resident #1 reported an allegation of sexual abused to a Certified Nursing Assistant (CNA-C ) with whom he had a personal friendship. Resident #1 stated he told CNA-C not to say anything but he was upset because CNA-B had performed oral sex on him while he was sleepy after pain medication and being bathed. Review of the facility's investigation documents revealed that on 1/7/2024, Resident #1 confided in CNA-C that he had been sexually violated. When Resident #1 confided in another CNA (CNA-E) on 1/8/2024, CNA-E immediately reported to her supervisor who then reported to the Director of Nursing. It was then that the implementation of the abuse policy began. On 2/22/2024 during the end of day meeting, an interview was conducted with the facility Administrator and Director of Nursing. During the interview, the Administrator and Director of Nursing stated they were very upset that an allegation of abuse was not immediately reported to the charge nurse so that the abuse protocol could be implemented. Both stated that all residents were at risk. The Director of Nursing stated the facility would immediately protect the resident, assess the resident, notify the physician and resident representative, and protect the resident and other residents from any further harm or incidents. The facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating was reviewed. Excerpts from the policy read, .Reporting Allegations to the Administrator and authorities: 1. If resident abuse, neglect is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Another excerpt stated that :immediately is defined as a. within two hours of an allegation involving abuse or result in bodily injury. The resident's plan of care was revised to reflect interventions to minimize recurrence. Resident #1 requested that no more male certified nursing assistants be assigned to care for him. Review of documentation sent to the Virginia State Board of Health Professions revealed that CNA-B and CNA-C were reported to the Board of Health Professions. Review of the documentation revealed the following documentation about implementing the abuse policy. (Facility's name redacted) Past Non Compliance Request 1. Yes, we had deficient practice. 2. Yes, the deficient practice occurred after the last survey. 3. Yes, we have presented sufficient evidence that the deficient practice has been corrected. a. All staff members were immediately re-educated on abuse policy and the reporting of abuse. b. The facility immediately reported the incident to the state agency, state licensing board and police. c. Employees were immediately contacted for a statement, suspended and removed from the schedule. d. Resident was seen by his Primary Physician and Psych seeing patient to help his through this traumatic event. e. Weekly audits conducted along with ADHOC (when necessary or needed) QAPI (Quality Assurance Performance Improvement) and Monthly QAPI reporting. 4. Yes, we now are in substantial compliance, and the deficient practice has not occurred again. a. Residents are asked 3 xs (three times) a week the abuse questions to ensure compliance b. No resident has reported abuse. c. Residents acknowledge they know whom to report abuse to and that staff ask then about it. 5. Facility is in compliance as of 1/8/24. Interviews were conducted with a total of over twenty staff members from all departments to include Nursing, Housekeeping, Laundry, Dietary, Maintenance and Administrative staff. All were able to state signs and symptoms of abuse, prevention of abuse, reporting immediately and to whom to report, and protecting the resident. They stated they could not return to work until they had the abuse training. They stated they know to report any suspicious behavior by coworkers. During the 4 days of survey, there were no observations, evidence, nor complaints of abuse expressed by residents. During the end of day debriefings on 2/26/2024 and 2/27/2024, the Administrator and Director of Nursing were informed of the findings. No further information was provided. The deficiency is cited at past non-compliance.

Based on interview, clinical record review, and facility documentation review, the facility staff failed to report an allegation of abuse within 2 hours of an allegation involving sexual abuse, for one resident (Resident #1) in a survey sample of 8 residents. The findings included: For Resident #1, a facility staff member, CNA (Certified Nursing Assistant )-C failed to identify and report an allegations of sexual abuse to the Administrator. Review of the facility's investigation documents revealed that on 1/7/2024, Resident #1 confided in CNA-C that he had been sexually violated. When Resident #1 confided in another CNA (CNA-E) on 1/8/2024, CNA-E immediately reported to her supervisor who then reported to the Director of Nursing. CNA-C did not report the allegation to the administrator. Interviews were conducted with the Administrator and the Director of Nursing. They were asked if the Certified Nursing Assistant should be able to identify and report abuse and neglect. The Administrator stated all the staff should be able to identify and report abuse and neglect. When asked if the incident was investigated, the Administrator stated it had not been until the day after the incident when Resident #1 informed another staff member (CNA-E). When asked if it was reported to the appropriate offices, the Administrator stated it had been reported to the appropriate offices as soon as the Director of Nursing and Administrator were made aware. A review of the facility Policy for Abuse read as follows: The facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating was reviewed. Excerpts from the policy read, .Reporting Allegations to the Administrator and authorities: 1. If resident abuse, neglect is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Another excerpt stated that :immediately is defined as a. within two hours of an allegation involving abuse or result in bodily injury. Review of documentation sent to the Virginia State Board of Health Professions revealed that CNA-B and CNA-C were reported to the Board of Health Professions. Review of the documentation revealed the following documentation about implementing the abuse policy. (Facility's name redacted) Past Non Compliance Request 1. Yes, we had deficient practice. 2. Yes, the deficient practice occurred after the last survey. 3. Yes, we have presented sufficient evidence that the deficient practice has been corrected. a. All staff members were immediately re-educated on abuse policy and the reporting of abuse. b. The facility immediately reported the incident to the state agency, state licensing board and police. c. Employees were immediately contacted for a statement, suspended and removed from the schedule. d. Resident was seen by his Primary Physician and Psych seeing patient to help his through this traumatic event. e. Weekly audits conducted along with ADHOC (when necessary or needed) QAPI (Quality Assurance Performance Improvement) and Monthly QAPI reporting. 4. Yes, we now are in substantial compliance, and the deficient practice has not occurred again. a. Residents are asked 3 xs (three times) a week the abuse questions to ensure compliance b. No resident has reported abuse. c. Residents acknowledge they know whom to report abuse to and that staff ask then about it. 5. Facility is in compliance as of 1/8/24. Interviews were conducted with a total of over twenty staff members from all departments to include Nursing, Housekeeping, Laundry, Dietary, Maintenance and Administrative staff. All were able to state signs and symptoms of abuse, prevention of abuse, reporting immediately and to whom to report, and protecting the resident. They stated they could not return to work until they had the abuse training. They stated they know to report any suspicious behavior by coworkers. During the 4 days of survey, there were no observations, evidence, nor complaints of abuse expressed by residents. There were no other residents identified as having had been abused by the CNA. During the end of day debriefing on 2/26/2024 and 2/27/2024, the Administrator and Director of Nursing were made aware of the concerns. No further information was provided. The deficiency is cited at past non-compliance.

Based on observation, staff interview, clinical record review, and the facility staff failed to ensure one Resident's environment (Resident #2) was free from strong foul urine odors in a survey sample of 5 Residents. The findings included: Resident #2's environment smelled very strongly of urine odor. Resident #2, was admitted to the facility on [DATE]. The Resident voluntarily discharged the same day due to complaints of strong urine odors in the building and an inoperable elevator. Progress notes were reviewed and revealed not a single entry in the clinical record. Resident #2 did have two MDS (minimum data set) assessments with an ARD (assessment reference date) of 11-30-22 which were coded as admit and discharge assessments, as the Resident did not stay a single night. Resident #2 was discharged , so her particular room could not be examined, however, during initial tour of the building and specifically the second floor area where the Resident had been admitted , had a pervasive odor of foul urine on the entire hall. The first floor also smelled of urine near the elevator entrance. During the initial tour of the second floor on 7-11-23 at 1:00 PM, two Residents in different rooms were noted to have wet pants and the Licensed Practical Nurse for the unit (LPN A) was in one of those rooms administering medications. She was alerted to the foul odor and the wet pants of a Resident who was standing in the hallway. She stated that he was very hard to redirect and that he would often refuse to be cleaned. She also stated that in the room where this interview took place was a Resident that had suffered a urinary tract infection recently for which he had finished a course of antibiotics, however, he still continued to have strong urine. That room smelled of urine had wet droplets of a creamy substance on the floor, and the floor was sticky. Lunch carts were in the hallway and meal trays had just begun to be served. These Residents had not yet received their trays, and any spilled food or liquids would have been there since breakfast, as the LPN stated floors had been mopped before breakfast. The Administrator, and DON were made aware of the findings and agreed with LPN A's statement that the Residents observed on the second floor had the issues observed that day. The Administrator, and DON were advised of the strong urine odor evident on the first and second floors. No further information was provided by the facility.

Based on Resident interview, staff interview, clinical record review, facility document review, the facility staff failed to accommodate the needs of one resident (Resident #4) in a survey sample of 5 residents. Resident #4 was 1) not provided an evening meal on the day of admission (4-12-23), 2) not provided any meal on 4-16-23 (Sunday) after another move the evening of 4-15-23 (Saturday night), and 3) not provided with a shower or tub bath during her stay. The findings included: Resident #4, was admitted to the facility on [DATE]. Diagnoses included; Gall bladder stones and cholecyctectomy. Resident #4's Admission MDS (minimum data set) coded Resident #4 as having no memory deficits and oriented to person, place, time and situation, with no cognitive deficits. The Resident required assistance of one staff member to perform some activities of daily living, such as bathing, and the Resident was ambulatory with a walker. On 7-11-23 at 2:00 p.m., Resident #4 was interviewed via phone conversation and found to be a good historian, oriented to person, place, time, and situation. The discharged Resident complained that the day of admission on 4-12-23 the staff did not provide her with a meal, as she entered the facility at 6:00 PM and staff stated they had finished meal delivery. She further stated that after her evening room change on 4-15-23 from the first floor to the second floor there was a mix up and she did not receive meals again on 4-16-23. She stated she had eaten some snacks she had on that day. The Resident went on to state that she did not receive a single tub bath or shower during the entire 10 day stay, and that was completely unacceptable to her. On 7-11-23 the clinical record and facility ADL (activities of daily living) records were reviewed. The review revealed no meals were served to Resident #4 on 4-12-23, and 4-16-23. Bathing records indicated that Resident #4 did not receive tub baths nor showers during her 10 day stay, and she was documented as having had bed baths provided by herself, indicating, no staff assistance. Resident #4's care plan was reviewed and revealed that the Resident was to receive ADL care assistance and meals as part of her skilled nursing admission. On 7-12-23 at 12:00 PM the DON (director of nursing), and Administrator were notified of above findings. No further information was provided.

Based on resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide pain management services for 1 resident (Resident #1) in the survey sample of 3 residents. The Findings included: The facility failed to 1a) administer physician-ordered pain medication. The facility failed to 1b) ensure that stretcher transportation (non-pharmacological intervention) was available transportation upon discharge. This resulted in unbearable positional pain, which constitutes harm. Resident #1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, with an assessment reference date of 1/31/22, was reviewed. Resident #1 was coded as a 1 (indicating almost constant pain). Resident #1 was coded as having pain that makes it hard to sleep at night, and that her day-to-day activities were limited because of pain. The numeric pain intensity rating scale was 7 out of 10. Resident #1 was coded as being able to make herself understood, and as sometimes being able to understand others. Her Brief Interview of Mental Status score was 7. According to the functional status, locomotion on and off the unit, as well as walking, were coded as 8 (did not occur). Mobility devices were coded as not being used were cane, walker, wheelchair, etc. Resident #1 was bed-bound. A review was conducted of the Care Plan, dated 1/25/22. An excerpt read: The resident has chronic pain r/t Arthritis, Diabetic [CONDITION(S)] .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 2/16/22, Resident #1's clinical record was reviewed. A signed physicians order dated February 2022 read, 1. [MEDICATION(S)] Capsule 100 MG [Milligrams]. Give 100 MG by mouth at bedtime for pain related to pain in unspecified joint. 2) [MEDICATION(S)] HCI Tablet 4 MG. [According to Mosby's Drug Guide for Nurses, Eighth Edition, [MEDICATION(S)] is a Controlled Substance schedule II pain medication. When taken by mouth, its duration lasts 4-5 hours]. Give 0.5 tablet by mouth every 6 hours as needed for pain related to acute pain due to trauma. 3) 1/28/22. Physical Therapy, treat 5/wk for 6 weeks for Therapeutic Exercises, Gait Training, Wheelchair Training .Patient/caregiver education/training and discharge planning. Resident #1 was discharged on [DATE]. According to the transportation company records, the transport van arrived at the facility at 10:00 A.M. The resident arrived at her home at 12:30 P.M. The 85- mile trip included a few delays so that the driver could check on Resident #1's positioning and pain level. According to the Medical Administration Record, Resident #1's last dose of [MEDICATION(S)] was administered the day before she was discharged . The medication ([MEDICATION(S)] 2 mg.) was documented as having been administered on 2/14/22 at 9:43 P.M. There was no documentation in the nurse's progress notes on 2/15/22 of a pain medication administration on the day of discharge. In addition, the Medication Audit Report for February 2022 confirms that there was no pain medication administered on 2/15/22 before Resident #1's discharge at 10:00 A.M. On 2/17/22 at noon an interview was conducted in the conference room with the Assistant Director of Nursing (Employee G). She stated, the Audit Report tells you what medication was given, the times, and the Resident's name. I review it during our clinical meetings daily. It tells what's missing. It documents refusals. The surveyor requested and received a copy of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On the 2nd day of the survey, the facility's Corporate Nurse (Employee M) submitted a Narcotic Count Sheet that had been altered via a line drawn partially covering the administration time of 9:00 A.M. on the day of discharge 2/15/22. The time was subsequently written in as 12:30 P.M. on 2/15/22. However, this administration was not substantiated by the Medication Audit Report. On 2/16/22, (1 day after discharge) a nurse wrote a late entry in the nurse's progress notes that the pain medication had been given (on 2/15/22) to Resident #1 in the transport van. However, Resident #1 was at her home approximately 85 miles away at 12:30 P.M. On 2/22/22, Resident #1's son was interviewed via telephone. He stated, I went out to meet the van on 2/15/22, 12:30 P.M. It was painful to hear the pain she was in. She was wailing, whimpering, and moaning. It was agony just to hear it. The facility did not give us any discharge paperwork. No prescriptions, no paperwork. She did not get any pain medication until she was admitted to the hospital the next day. Resident #1 was in her bedroom with her son at the time of the interview. She was also interviewed via telephone. Resident #1 stated, I told them (facility staff) that I was even willing to wait another day because I didn't want to sit in a wheelchair. They shoved me in that wheelchair. Even the van driver lady (Employee P) didn't think it was right to take me in a wheelchair. It's been a long time since I was able to sit up in a chair, since 2015. I cannot lift my head. I am always hunched over. I've had several back surgeries. I have metal in my back. You can look at my back and tell. I almost didn't make it. I can't describe how bad the pain was. It was indescribable. I thought I was going to die. They didn't give me any pain medications. They made me leave on the wheelchair van. On 2/22/22 at approximately 11:25 A.M., the transport driver (Employee P) was interviewed. She stated, She [Resident #1] was in a lot of pain. She told the [facility] social worker [Employee J] that she was in pain. She told me that she was in pain. I questioned the social worker and physical therapist [Employee H] if she should be in a wheelchair. [Resident #1] said that she wanted to go lay back down. I told them [facility staff] that she needed a stretcher. [Employee J] stated that she'd go back inside the facility and check. She came back and said that the resident could use the wheelchair. The physical therapist guy helped me put pillows around [Resident #1]. During to trip, the resident was screaming in pain saying, 'I hurt .I hurt'. I kept checking on her. She said, 'please don't leave me in this wheelchair'. She was in pain sitting up in the wheelchair. She needed a stretcher. On 2/18/22, the transport company owner submitted a written statement. An excerpt read, [Transport company] received a request from [facility social worker/discharge planner - Employee J] for a wheelchair transport on 2/15/22 at 10:00 A.M. Upon arrival to the facility the driver inquired if the patient would be more comfortable transporting on a stretcher instead of a wheelchair. The discharge planner confirmed that it was their interdisciplinary team's clinical recommendation that the patient could transport via a wheelchair, and that a stretcher was not necessary for the trip. The discharge planner stated that the patient was discharged . She encouraged the driver to depart the facility. The driver contacted dispatch and advised the team that the offer to transport by stretcher had been declined by the facility. The driver attempted to reassure the patient and offered to stop and reposition her as needed. On 2/16/22, a review was conducted of Resident #1's clinical record. Her Physical Therapy and Occupational therapy notes revealed there was no evidence of a wheelchair assessment. On 2/16/22, at approximately 4:00 P.M. in the Assistant Director of Nursing's office (Employee G), The Director of Rehabilitation (Employee D) was interviewed, along with the Occupational Therapist (Employee H). Their sister facility Administrator (Employee L) observed the interview. The Director of Rehabilitation (Employee D) stated that the clinical record contained entries documenting that Resident #1 could only tolerate sitting in a wheelchair for up to 1 hour and that she believed that a stretcher was needed for transportation during an 85-mile trip. Employee D submitted the following written statement: I (Employee D) attest that to the best of my knowledge, [Resident #1] was able to comfortably tolerate a standard wheelchair for 1 hour before requesting to be returned to bed. If I had been asked, I would have recommended stretcher transportation for travel over 1 hour. Employee H stated, It fluctuated where she would be in pain - it would affect her participation .She was very frail. I have not seen her ever sitting up in a chair. She is normally laying down. I saw her when she left . I helped put pillows around her .She was complaining of pain. She seemed frightened. She was very small and frail. During the interview, both the social worker (Employee K) and the Director of Social Services, (Employee J) joined the interview. Both social workers stated that they were aware that Resident #1 should have been transported in a stretcher. Employee K stated that she was present when Resident #1 was being put into a wheelchair for transportation, She further stated that Resident #1 informed her that she was in pain. She stated that she informed a nurse of the pain, and brought a few pillows to Resident #1 because the driver was concerned about the suitability of the wheelchair. Both social workers stated that between the two of them, they attended all of Resident #1's discharge planning meetings, and the interdisciplinary team never discussed using a stretcher for transport. The Director of Social Services (Employee J) stated, I informed the resident's family that the cost of transportation was $250.00 - $475.00 depending on if you are going to use a wheelchair or a stretcher. She stated that she was aware that the resident's family had paid $475.00 to the transportation company. She did not inform the family that $475.00 was the cost for a wheelchair with oxygen transport, not stretcher transport. This means the social worker gave the family inaccurate information. The Director of Social Services was interviewed again in her office on 2/17/22 at approximately 10:30 A.M. She stated All disciplines should be actively involved in the decision to discharge .it is no one but my responsibility to make sure the transportation was correct. I was informed by the therapy department today [2 days after Resident #1's discharge)] that the resident could go home in a wheelchair or on a stretcher. I am a Social Worker. I am not qualified to determine if a wheelchair or a stretcher should be used. I was not aware that Resident #1 was bed-bound. On 2/17/22 a review of facility documentation was conducted. The facility Rehab Serviced Discharge Policy dated 7/27/21 was reviewed. An excerpt read, When the discharge date is established, recommendations for the home or follow-up care are provided for the patient and/or caregivers including a home assessment, acquisition of equipment, written instruction, and how to access available community resources if needed. A review of the physical therapy and occupational therapy notes revealed that there was no recommendation regarding the use of a wheelchair or a stretcher for transportation home upon discharge. On 2/22/22 and 2/23/22 the Administrator (Employee A), The Clinical Consultant (Employee M), and the Director of Nursing (Employee B) were informed of the findings. No further information was received.

Based on resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to develop and implement an effective discharge planning process for 2 residents (Resident #1, Resident #2) in the survey sample of 3 residents. This resulted in harm for Resident #1. The Findings included: For Resident #1, who was bed-bound, the facility failed to develop and implement a discharge plan for stretcher transportation (non-pharmacological intervention) and failed to administer pain medication. According to Resident #1, her family member, and the Transportation Driver, it resulted in unbearable positional pain, which constitutes harm. Resident #1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, with an assessment reference date of 1/31/22, was reviewed. Resident #1 was coded as a 1 (indicating almost constant pain). Resident #1 was coded as having pain that makes it hard to sleep at night, and that her day-to-day activities were limited because of pain. The numeric pain intensity rating scale was 7 out of 10. Resident #1 was coded as being able to make herself understood, and as sometimes being able to understand others. Her Brief Interview of Mental Status score was 7. According to the functional status, locomotion on and off the unit, as well as walking, were coded as 8 (did not occur). Mobility devices were coded as not being used (cane, walker, wheelchair, etc.). Resident #1 was bed-bound. A review was conducted of the Care Plan, dated 1/25/22. An excerpt read: The resident has chronic pain r/t Arthritis, Diabetic [CONDITION(S)] .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 2/22/22, Resident #1's son was interviewed via telephone. He stated, I went out to meet the van on 2/15/22, 12:30 P.M. It was painful to hear the pain she was in. She was wailing, whimpering, and moaning. It was agony just to hear it. The facility did not give us any discharge paperwork. No prescriptions, no paperwork. She did not get any pain medication until she was admitted to the hospital the next day. Resident #1 was in her bedroom with her son at the time of the interview. She was also interviewed via telephone. Resident #1 stated, I told them (facility staff) that I was even willing to wait another day because I didn't want to sit in a wheelchair. They shoved me in that wheelchair. Even the van driver lady (Employee P) didn't think it was right to take me in a wheelchair. It's been a long time since I was able to sit up in a chair, since 2015. I cannot lift my head. I am always hunched over. I've had several back surgeries. I have metal in my back. You can look at my back and tell. I almost didn't make it. I can't describe how bad the pain was. It was indescribable. I thought I was going to die. They didn't give me any pain medications. They made me leave on the wheelchair van. On 2/22/22 at approximately 11:25 A.M., the transport driver (Employee P) was interviewed. She stated, She was in a lot of pain. She told the social worker [Employee J] that she was in pain. She told me that she was in pain. I questioned the social worker and physical therapist [Employee H] if she should be in a wheelchair. [Resident #1] said that she wanted to go lay back down. I told them that she needed a stretcher. [Employee J] stated that she'd go back inside the facility and check. She came back and said that the resident could use the wheelchair. The physical therapist guy helped me put pillows around [Resident #1]. During to trip, the resident was screaming in pain saying, 'I hurt .I hurt'. I kept checking on her. She said, 'please don't leave me in this wheelchair'. She was in pain sitting up in the wheelchair. She needed a stretcher. On 2/18/22, the transport company owner submitted a written statement. An excerpt read, [Transport company] received a request from [facility social worker/discharge planner - Employee J] for a wheelchair transport on 2/15/22 at 10:00 A.M. Upon arrival to the facility the driver inquired if the patient would be more comfortable transporting on a stretcher instead of a wheelchair. The discharge planner confirmed that it was their interdisciplinary team's clinical recommendation that the patient could transport via a wheelchair, and that a stretcher was not necessary for the trip. The discharge planner stated that the patient was discharged . She encouraged the driver to depart the facility. The driver contacted dispatch and advised the team that the offer to transport by stretcher had been declined by the facility. The driver attempted to reassure the patient and offered to stop and reposition her as needed On 2/16/22, at approximately 4:00 P.M. in the Assistant Director of Nursing's office (Employee G), The Director of Rehabilitation (Employee D) was interviewed, along with the Occupational Therapist (Employee H). Their sister facility Administrator (Employee L) observed the interview. The Director of Rehabilitation (Employee D) stated that the clinical record contained entries documenting that Resident #1 could only tolerate sitting in a wheelchair for up to 1 hour and that she believed that a stretcher was needed for transportation during an 85-mile trip. She submitted the following written statement: I (Employee D) attest that to the best of my knowledge, (Resident #1) was able to comfortably tolerate a standard wheelchair for 1 hour before requesting to be returned to bed. If I had been asked, I would have recommended stretcher transportation for travel over 1 hour. Employee H stated, It fluctuated where she would be in pain - it would affect her participation .She was very frail. I have not seen her ever sitting up in a chair. She is normally laying down. I saw her when she left . I helped put pillows around her .She was complaining of pain. She seemed frightened. She was very small and frail. During the interview, both the social worker (Employee K) and the Director of Social Services, (Employee J) joined the interview. Both social workers stated that they were aware that Resident #1 should have been transported in a stretcher. Employee K stated that she was present when Resident #1 was being put into a wheelchair for transportation, She further stated that Resident #1 informed her that she was in pain. She stated that she informed a nurse of the pain, and brought a few pillows to resident #1 because the driver was concerned about the suitability of the wheelchair. Both social workers stated that between the two of them, they attended all of Resident #1's discharge planning meetings, and the interdisciplinary team never discussed using a stretcher for transport. The Director of Social Services (Employee J) stated, I informed the resident's family that the cost of transportation was $250.00 - $475.00 depending on if you are going to use a wheelchair or a stretcher. She stated that she was aware that the resident's family had paid $475.00 to the transportation company. She did not inform the family that $475.00 was the cost for a wheelchair with oxygen transport, not stretcher transport. The social worker gave the family inaccurate information. The Director of Social Services was interviewed again in her office on 2/17/22 at approximately 10:30 A.M. She stated All disciplines should be actively involved in the decision to discharge .it is no one but my responsibility to make sure the transportation was correct. I was informed by the therapy department today (2 days after Resident #1's discharge) that the resident could go home in a wheelchair or on a stretcher. I am a Social Worker. I am not qualified to determine if a wheelchair or a stretcher should be used. I was not aware that Resident #1 was bed-bound. On 2/17/22 a review of facility documentation was conducted. The facility Rehab Serviced Discharge Policy dated 7/27/21 was reviewed. An excerpt read, When the discharge date is established, recommendations for the home or follow-up care are provided for the patient and/or caregivers including a home assessment, acquisition of equipment, written instruction, and how to access available community resources if needed. A review of the physical therapy and occupational therapy notes revealed that there was no recommendation regarding the use of a wheelchair or a stretcher for transportation home upon discharge. On 2/22/22 and 2/23/22 the Administrator (Employee A), The Clinical Consultant (Employee M), and the Director of Nursing (Employee B) were informed of the findings. No further information was received. 2) For Resident #2, the facility staff failed to ascertain her home accessibility limitations. The facility staff failed to ensure that Resident #2 had a wheelchair to facilitate ambulation from the car to the apartment, resulting in Resident #2 being forced to remain in her car for two hours, awaiting someone who could carry her to the apartment. Resident #2 was admitted to the facility on [DATE], and discharged on [DATE]. According to the signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An excerpt read: PT (Physical Therapy) Clarification: PT to treat 5 x week for 6 weeks for Therapeutic exercises. Wheelchair Training .Pressure reducing Cushion to wheelchair. The Physical Therapy Discharge Summary, dated 2/11/22 was reviewed. An excerpt read: Ambulation 20 feet with contact guard. According to Resident #2's daughter, the distance from their nearest parking space to their apartment is 50 feet away, and two steps up. A review was conducted of the Minimum Data Set, dated dated dated [DATE]. Resident #2 was coded as requiring extensive weight-bearing assistance of one person walking. The mobility device was documented as being a walker. Resident #2 was coded as Walk 50 feet: Not attempted due to medical condition or safety concerns. Resident#2's Brief Interview of Mental Status Score was 10, indicating moderately impaired cognition. Resident #2's Care Plan was reviewed. An excerpt read: 2/8/22. The resident is at risk for falls. Minimize the risk of sustaining a serious injury through the review date. On 2/22/22 at 1:15 P.M., a telephone interview was conducted with Resident #2's daughter. She stated, I am [AGE] years old. My mother is [AGE] years old. I can't handle her. The facility was supposed to get my mother a wheelchair to take home with her. I had to bring her home without the ability for her to be mobile. As of today, they still haven't sent her a wheelchair. I wasn't informed that there was no wheelchair until I went to pick her up after she was discharged . They let me borrow a wheelchair to get her to the car, but then I had to return it. I had no way to get her from the car to the apartment. It's 50 feet away, and up two stairs. We were stuck in the parking lot for two hours until I could get someone to help us. She wasn't able to move at all. She is cold-natured. She doesn't like the cold. On 02/22/2022 at 3:05 P.M., Employee C, physical therapist, was interviewed by Surveyor C. When asked about Resident #2's functional ability at the time of discharge, Employee C referred to Resident #2 clinical record [physical therapy notes] and stated that Resident #2 required minimal assistance for transfers. When asked what that meant, Employee C stated that it was not safe forResident #2 to transfer herself because Resident #2 was not steady to transfer herself and required minimal assistance. Employee C also stated that Resident #2 was able to stand 1-2 minutes without holding on to anything and was able to walk 20 feet with a front-wheeled walker with touch assistance (meaning someone standing by touching Resident to assist with balance). When asked about the recommendations for assistive devices pertaining to how Resident #2 would get from the vehicle to the home upon discharge, the physical therapist referred to the clinical record and stated that there wasn't enough documentation in Resident #2's clinical record to tell what was needed. The physical therapist then referred to the occupational therapy notes and stated if there were no stairs, a wheelchair would be recommended. When asked if Resident #2's home had stairs, Employee C indicated that the documentation didn't address if there were stairs or not. Employee C also stated that usually the therapist would note that in the documentation and add a goal to negotiate stairs without help to transition home. This surveyor and the physical therapist observed in the therapy documentation that Resident #2 lived in a first-floor apartment with her daughter and granddaughter. There was no evidence in the documentation addressing stairs or distance from the vehicle to the apartment. On 02/22/2022 at 3:35 P.M., the Director of Rehab was interviewed by Surveyor C. When asked about Resident #2's functional status at the time of discharge, the Director of Rehab referred to Resident #2's clinical therapy notes and stated that Resident #2 was able to walk a maximum of 20 feet with a walker and contact guard. When asked what contact guard meant, the Director of Rehab stated She would just need someone walking by her and having a hand on her back to steady her. When asked about the distance between the vehicle and the apartment, the Director of Rehab stated she didn't know and indicated if it was less than 20 feet, Resident #2 could use a walker with contact guard assistance. When asked if Resident #2 had a walker upon discharge, the Director of Rehab stated, She should have [had one]. When asked about the recommendation if the distance was greater than 20 feet, the Director of Rehab stated that Resident #2 would have needed a wheelchair. When asked if there were stairs to navigate at Resident #2's home, the Director of Rehab stated that I would hope that family would give us a head's up whether or not there were stairs or a curb. When asked again if there were stairs, the Director of Rehab stated the documentation didn't say explicitly there were stairs but it implies there were no stairs. The Director of Rehab then stated that a typical set up for senior living on the first floor should be a straight shot from the vehicle to the apartment. Resident #2 lived with her daughter and granddaughter in a regular apartment. On 2/22/22 and 2/23/22 the Administrator (Employee A), The Clinical Consultant (Employee M), and the Director of Nursing (Employee B) were informed of the findings. No further information was received.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct outbreak testing for 9 of 26 Residents (Residents #2, #7, #8, #9, #10, #11, #12, #24 & #25) and 10 of 14 staff (Employee E, Employee F, LPN C, LPN D, CNA A, CNA C, CNA E, CNA F, CNA G & CNA I). Failure to test during an outbreak reduces the facility's ability to contain the outbreak and increases the likelihood that serious harm, impairment, or death related to COVID-19 will occur. Immediate Jeopardy was identified on 09/30/2020 at 2:30 PM and the facility staff were notified at 4:15 PM. After verification, Immediate Jeopardy was abated on 10/5/2020 at 2:30 PM. The findings included: The facility staff failed to conduct testing of Residents and staff during an active COVID-19 outbreak starting 08/26/2020 and continued through the survey. Note: The regulation 483.80 (h) COVID-19 Testing did not become effective until 09/02/2020. Non-testing before that date was not included as part of the deficient practice. On 9/15/2020 during a review of the facility employee records the following was revealed: * Employee E had no documentation of testing after 9/02/2020. Review of the testing log, provided by the facility, revealed that Employee E's name was omitted from the testing log. *Employee F had no evidence of any COVID testing after 9/02/2020. Review of the testing log, provided by the facility, revealed Employee F's name was omitted from the testing log. *On 9/15/2020 during a facility tour CNA A, told Surveyor A she had not been tested for COVID-19. The facility staff provided no evidence of COVID testing for CNA A after 9/02/2020. On 9/15/2020 at 4:09 PM the facility Human Resources staff indicated she had no additional COVID test results for Employees E, F or CNA A. On 9/15/2020 at 3:54 PM an interview was conducted with the infection preventionist (IP) employee, (Admin employee D). She indicated that the facility is testing staff and Residents weekly. She stated the facility sends a blast text to all staff to notify of test dates, if they don't come they call them. She stated that refusals of testing is addressed in their pandemic plan. Surveyor A reviewed the testing log with the IP and both agreed it doesn't indicate weekly testing is being conducted. On the afternoon of 9/15/2020 during an interview with the Corporate Nurse, she indicated the facility had performed testing on 8/27/2020 but the lab specimens were sent to the wrong lab and were not able to be processed. They facility therefore, had to perform retesting on 8/31/2020. The facility staff performed another round of testing on 9/8/2020 and again the lab specimens were sent to the wrong lab and were not able to be processed. The facility staff performed re-testing on 9/10/2020. Review of the current Resident listing provided to the survey team on 9/15/2020 by the facility staff, revealed several Residents who were omitted from the testing log. On 9/29/2020 at approximately 1 PM, the facility staff provided the survey team with a testing log, (same log provided on 9/15/2020). They also provided the following logs and data that had not been presented or provided to the survey team on 9/15/2020 - 9/16/2020: * additional testing logs of staff tested on [DATE]. * 3 employee lists, each with a separate test date hand written on the top and check marks beside employee names which indicated they were tested for COVID-19 on the test dates written on the forms. * Another Resident log of testing performed from 8/25/2020-9/10/2020 Review of the multiple logs and testing data submitted was reviewed and when compared to the current Resident list and current Employee list revealed the following: * 13 Employees were omitted from the testing log. * The test date of 9/15/20 revealed 51 employee names listed with no indication they were tested . * The employee test date of 9/22/20 revealed 26 employee names without a check mark to indicate they had been tested . * The employee test date of 9/29/20 had 60 employee names with no check mark to indicate they had been tested . * There was no indication of any employee testing being conducted between 09/02/2020 - 9/14/2020. * There were 11 Residents on the facility census dated 8/27/2020 that were not listed on the testing log. *There were 9 Residents on the facility census sheet dated 9/29/2020 that were not on the testing log. On 9/30/2020 COVID test results were requested for a sampling of Residents and Employees. Review of that data revealed the following: *Resident #2 was admitted on [DATE] and there was no evidence they had ever been tested for COVID-19. Review of the COVID testing log revealed Resident #2 name was omitted from the testing log. Further reviewed revealed Resident #2 refused COVID testing on 8/26/2020 & again on 9/10/2020. However, there was no indication in the clinical record that any attempts were made to test Resident #2 after the 9/10/2020 refusal. Resident #2 was documented as having refused vital signs and nursing assessments often (several times weekly) for COVID monitoring. The resident missed scheduled facility test dates on 9/3/2020, 9/17/2020, and 9/25/2020. There was no documentation that Resident #2 refused testing on those dates. * Resident #7 was tested [DATE] and again 9/10/2020. The resident missed scheduled the facility test date on 9/3/2020. * Resident #8 was tested on [DATE] & again on 9/22/2020. The resident missed scheduled facility test dates on 9/3/2020, 9/17/2020, and 9/25/2020. * Resident #9 was tested for COVID 9/3/2020, 9/17/2020, 9/25/2020. The resident missed scheduled facility test date on 9/10/2020. * Resident #10 was tested on [DATE] and 9/17/2020. The resident missed scheduled facility test dates on 9/3/2020 and 9/25/2020. * Resident #11 was tested on [DATE] and 9/25/2020. The resident missed scheduled facility test dates on 9/3/2020 and 9/10/2020. * Resident #12 was tested on [DATE], 9/17/2020, and 9/25/2020. The resident missed scheduled facility test date on 9/3/2020. * Resident #24 missed scheduled facility test dates on 9/3/2020 and 9/10/2020. The resident tested positive for COVID on 9/13/2020 after being sent to the hospital. * Resident #25 was tested [DATE], 9/17/2020, and 9/25/2020. The resident missed scheduled facility test date on 9/3/2020. *Employee E had results of a single negative COVID test on 8/27/2020. No other COVID testing was provided for this employee and when records were requested on 9/15/2020 this is the only test result provided. Review of the employee lists provided on 9/29/2020 revealed Employee E was tested on [DATE], 9/15/2020, 9/22/2020, 9/29/2020. There are 13 days between 9/2/2020 and 9/15/2020. * Employee F had results of a negative COVID test from a test date of 6/18/2020. The facility provided no further records on 9/15/2020 & 9/16/2020. Review of the employee lists provided on 9/29/2020 revealed Employee F was tested on [DATE], 9/15/2020, 9/22/2020 and 9/29/2020. There are 13 days between 9/2/2020 and 9/15/2020. * LPN C: the facility provided a copy of a text message with a COVID result of negative from a sample collected on 8/26/2020, 9/3/2020 & 9/20/2020. The document had no identifying information other than a handwritten name of LPN C. There are 17 days between 9/3/2020 and 9/20/2020. * LPN D: the facility provided no documentation of any COVID testing as requested. *CNA A: On 9/15/2020 during a facility tour CNA A, told Surveyor A she had not been tested for COVID-19. The facility staff provided no evidence of COVID testing for CNA A. *CNA C was tested for COVID on 9/22/2020. There are 20 days between 9/2/2020 and 9/22/2020. *CNA E was tested for COVID on 9/17/2020. The facility staff provided a copy of a text message with a COVID result of negative from a sample collected on 9/25/2020. However, the document had no identifying information other than a handwritten name of CNA E. There are 15 days between 9/2/2020 and 9/17/2020. * CNA F: the facility provided no documentation of any COVID testing as requested. * CNA G: the facility provided no documentation of any COVID testing as requested. * CNA I: the facility provided no documentation of any COVID testing as requested. Review of the facility policy titled COVID-19 Pandemic Plan with a revision date of 9/9/2020 read, Outbreak testing: Test all staff and residents in response to an outbreak (defined as any single new infection in staff or any nursing home onset infection in a resident). A resident who is admitted to a center with COVID-19 does not constitute a center outbreak. Continue to test all staff and residents that tested negative every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. This policy further read, Testing Refusal: Staff: Staff who refuses testing during an Outbreak (as defined above), is prohibited from work until the outbreak testing has been completed. Staff who refuses routine testing, will be immediately excluded from work until staff complies with testing requirements. The Centers for Disease Control and Prevention (CDC) stated: Testing asymptomatic residents with known or suspected exposure to an individual infected with [DIAGNOSES REDACTED]-CoV-2, including close and expanded contacts (e.g., there is an outbreak in the facility): Perform expanded [MEDICAL CONDITION] testing of all residents in the nursing home if there is an outbreak in the facility (i.e., a new [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or any nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident). A single new case of [DIAGNOSES REDACTED]-CoV-2 infection in any HCP (health care personnel) or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html The CDC further states: Continue repeat [MEDICAL CONDITION] testing of all previously negative residents, generally every 3 days to 7 days, until the testing identifies no new cases of [DIAGNOSES REDACTED]-CoV-2 infection among residents or HCP for a period of at least 14 days since the most recent positive result. This follow-up [MEDICAL CONDITION] testing can assist in the clinical management of infected residents and in the implementation of infection control interventions to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html Immediate Jeopardy was identified on 09/29/2020 at 2:30 PM and the facility staff were notified at 4:15 PM. The facility presented the following removal plan: F886 Immediate Jeopardy Abatement 9/30/2020 The facility staff failed to conduct required comprehensive COVID-19 testing of both residents and staff members, for a minimum of every 3-7 days, while experiencing an active outbreak of COVID-19 within the facility. Upon review of a sample of 25 resident records, 9 residents were found not to have received the required COVID-19 testing during an active outbreak within the facility. Upon review of a sample of 14 staff records, 10 staff members were found not to have received the required COVID-19 testing during an active outbreak with the facility. 1. Testing of residents occurred on 9/29/20 and 9/30/20. All current resident with the exception of positive residents and the one resident who refused have been tested (including 8 of the 9 identified and COVID testing results are pending. The one resident who continues to exercise her choice to refuse and has been quarantined. As of 9/30/2020 at 10pm, 5 of 10 staff members have received COVID testing while the remaining 5 of 10 staff members have been notified that they have been removed from the schedule until they are able to be tested and or produce negative test results within the last 3 days. Otherwise, these employees will remain out of work while for the duration of outbreak and positivity rate related testing. 2. A) Scheduled weekly outbreak testing of current residents with previous week negative results was completed by a Registered Nurse as of 9/30/20. 1 resident activated her right to refuse testing and was transferred to a room on the designated warm unit and placed on quarantined due to her consistent refusals. She remains asymptomatic at this time but will remain in quarantine until the outbreak has ended. The residents tested were reconciled against the current census to verify all resident have been tested or quarantined. B) Outbreak testing of current staff members has been completed as of 9/30/2020 at 10pm. Staff tested was reconciled against the staff roster to verify all staff were tested . The staff that were not tested on ,[DATE] and 9/30/2020 were identified and have been notified that they have been removed from the schedule until they are able to produce a negative COVID test result that coincides with the current test week. Staffing agencies were contacted to inform their staff assigned to the facility to bring test results done within prior 7 days with them when reporting for duty for the 1st time. 3. A. The Vice President of Operations has educated the Executive Director and Director of Clinical Services on the CMS process on COVID testing as of 9/30/2020 at 430pm to include; Testing of all staff and residents in response to an outbreak-any single new infection in staff or resident. Facility will monitor the county positivity rate every other week and adjust the frequency of performing staff testing accordingly. If the 48 hour turn-around time cannot be met by the processing lab for any reason, the center should have documentation of its efforts to obtain quick turnaround testing results and contact with the local and state health department. Staff experiencing symptoms are expected will be restricted from facility pending results. Residents with signs or symptoms - will be placed on transmission based precautions pending results. B. The DCS or designee will make a current list of each resident who should be tested and copies will be distributed to staff to be used to conduct the testing. Once the testing has been conducted the DCS or designee will reconcile the list to verify all residents who require testing have been and follow up to verify residents get tested or staff have documented the refusal and education about testing. DCS or designee will ensure residents who refuse are quarantined until tested or the remainder of the outbreak. C. The DSC/designee will enter the data on a spreadsheet updating per testing of resident and staff with testing dates and outcomes of testing to maintain documentation of testing. D. DCS or designee will check agency staff to verify staff scheduled to be at the facility have current testing and those who do not will have rapid POC [MEDICATION NAME] test performed upon arrival in addition to screening. 4. Ad hoc QAPI was conducted on 10/1/2020 with the IDT to review the outlined planned. Completion of the above plan will be as of 10/1/2020 at 1pm. During verification the survey team determined that the last Resident testing for COVID was performed on 10/4/2020 at 5:25 PM, not on the completion date of 10/1/2020 as submitted. After verification, Immediate Jeopardy was removed on 10/05/2020 at 2:30 PM.

Based on interview, clinical record review, facility documentation and in the course of an investigation, the facility staff failed to ensure Residents are free from accidents and hazards for 1 Residents (#1) in a survey sample of 5 residents, resulting in hospitalization for Resident #1. This is harm. The findings included: 1. For Resident #1 the facility staff failed to provide adequate supervision to ensure the resident was free from accident hazards. Resident #1 had 8 falls in 4 months. He fell on [DATE] (complained of pain to right shoulder however x-ray was negative for fracture); 7/30/20 (Laceration to left eyebrow and skin tear to left elbow. Sent to ER for evaluation, returned with sutures to left eyebrow area.; 8/08/20 (skin tear to left elbow); 8/18/20 (skin tears to left hand and wrist); 8/20/20 (No injury noted); 9/02/20 (laceration over left eye, 3 skin tears to left arm. Sent to ER for evaluation. Returned with 4 sutures over left eye); 9/03/20 (abrasion on right upper arm, skin tear to right hand and hematoma on right side of forehead. Sent to ER. Head CT negative, X-ray of right arm negative). His last fall was on 9/04/20 when he was admitted to the hospital for left maxilla (upper jaw) fracture, left orbit (eye socket) fracture and left zygomatic (cheekbone) arch fracture and mildly displaced Left lateral sixth -eighth rib fractures and Posterior left fourth and fifth rib fractures. This is harm. Resident #1, a [AGE] year old man admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/31/20 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 6 indicating severe cognitive impairment. Also the MDS Section G- Functional Status, B. Transfers -independently with 0 physical assistance. Section C. Walking in the room [ROOM NUMBER]. Supervision, 1. Set up help only. Section D. walking in the corridor 1. Supervision, 1. Set up help only. Section E. & F. Locomotion On and Off the unit 1. Supervision, 1. Setup help only. Section G 0600 - Coded the Resident as using a wheelchair for mobility. On 9/23/20 a review of the clinical record revealed that Resident #1 had 8 falls during his stay at the facility from 5/23/20 until 9/4/20. A review of the care plan revealed The Resident was care planned for falls as follows: FOCUS: (Resident name redacted) has had an actual fall with Poor Balance. Date Initiated 6/10/20 GOAL: The resident will resume usual activities and minimize the risk of further incident through next review date. Date Initiated - 6/10/20 Revision on: 6/11/20 Target date 12/2/20. INTERVENTIONS: Closer Observation Date Initiated - 9/2/20 Revision On: 9/7/20 (note revision after resident was discharged and admitted to the hospital) Neuro checks as ordered-Date Initiated 9/2/20 (Note this is not an intervention this is done post fall) Medication Review - Date Initiated 7/31/20 Provide appropriate activities and guided exercises as tolerated. Date Initiated - 8/9/20 PT consult for strength and mobility. Date Initiated 6/10/20 Revision on 6/11/20 X-Ray as ordered Date Initiated - 6/10/20 (Note: this is not an intervention this is doctors order post fall) FOCUS: (Resident name redacted) is at risk for falls r/t confusion, dementia, incontinence, [MEDICAL CONDITION], diabetes, and hypertension. Date Initiated 6/16/20 Revision on 6/16/20: GOAL: Minimize risk of falls through next review date. Date Initiated - 6/16/20 Target date 12/2/20. INTERVENTIONS: Anticipate and meet the resident's needs Date Initiated - 6/16/20 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated 6/16/20 Bed in low position - Date Initiated 6/16/20 Educate the resident / resident's representative / caregivers about safety reminders and what to do if a fall occurs Date Initiated - 6/16/20 Ensure the resident is wearing appropriate footwear/nonskid socks when ambulating Date Initiated - 6/16/20 PT evaluate and treat as ordered or PRN. Date Initiated 6/10/20 (Note: The care plan was not updated and no interventions were put in place for the falls on 8/18, 8/20, 9/3, and 9/4) On 9/23/20 at 1:25 PM an interview was held with the ADON who was asked what the nurse should do if a fall occurs. She stated Well first you assess to see if the Resident is hurt. Then you check the vital signs, start neuro checks if it is unwitnessed or if they hit their head, contact the MD and the RP, fill out a SBAR or change in condition form, chart a nurses note and update the care plan with new interventions after each fall. She was asked who does the care planning is it any nurse or does one person have that job, she stated, All nurses have access to update the care plan. On 9/24/20 approximately 2:00 PM requested a list of all of the falls from 4/1/20 through 9/24/20 the facility submitted a list that included seven of the eight falls that Resident 1 sustained. The list was missing the fall on August 18. On 9/24/20 at approximately 10:30 AM and interview with the DON and ADON and Corporate Nurse was held. The survey team requested copies of the fall investigations for all falls sustained by Resident #1 during his admission. The DON was asked what the nurses responsibility when there is a fall. She replied She should assess the Resident, notify the MD/RP, write a note in the chart, complete an SBAR or Change of Condition and if it is unwitnessed or the Resident has a head injury they should to neuro checks as well. The first fall occurred on 6/10/20. A nursing note dated 6/10/20 at 1:50 PM the note reads: Late entry patient found on the floor between the bed and the window laying on his left side. Patient assessed able to move all extremities, however guard to the left arm VS 117/68, 71, 20, 97.7, Neuro checks initiated within normal limits when asked what he was trying to do, patient responded lift the bed. Nurse asked what for I said to tighten the bolts earth asked (NP name redacted) to see patient new order for stat CBC/CMP/urine and obtain x-rays of left shoulder and left humerus. Left VM (voicemail) for RP (name redacted) to call facility awaiting call back will continue to monitor for changes. LPN (name redacted). Note: The facility stated they could not locate the neuro flow sheet for this unwitnessed fall The second fall occurred on 7/30/20. Nurse's note dated 7/30/20 at 7:25 PM reads: VS-BP 137/72 HR - 65, T - 96.2 RR - 20 SPO2 -92% Resident was found on the floor laying on the left side. Laceration noted to the left upper eye; skin tear to left elbow. Resident is awake, conscious, and breathing. Resident was sent out via stretcher. EMS was given face sheet, order summary/medication list. Gave report to (name redacted) at (hospital name redacted) faxed over face sheet, SBAR, hospital transfer form. Notified nurse that patient has no present signs or symptoms of COVID-19 will follow up with resident status (LPN name redacted). The results of a fall risk evaluation dated 7/31/20 read that the resident is a High fall risk. A physicians note dated 7/31/20 reads: Chief Complaint/Nature of Presenting Problem: Fall f/u and laceration above the eye. Resident seen and examined. All medications, labs and medical records were reviewed. Discussed plan of care with nursing staff in detail resident sustained [REDACTED]. Monitor for signs six symptoms of infection remove sutures on 8/7/20 continue with all other medications along with safety and fall precautions (NP name redacted) 7/31/20 11:57 PM The facility submitted a fall risk evaluation dated 8/8/20 at 5:30 PM, again indicating that the resident is a High fall risk, A nurses note dated 8/8/20 read: 8/8/20 at 5:30 PM resident was found on the floor lying on his back. Skin tear noted to the left elbow; minimal bleeding noted. Site cleansed with normal saline and covered with dry dressing. No changes in cognitive status. NP/RP/notified. Will continue to monitor for bleeding and bruising (LPN name redacted). Regarding the fall on 8/18/20 6:03 PM the facility did not have fall investigation. A nurse's note dated 8/18/20 read as follows: 8/18/20 at 8:03 patient was trying to get into the empty bed located in his room and fell on the floor, patient was found on his left side, patient stated that he did not hit his head on anything just his hand and elbow, patient has skin tears to the left hand, wrist, VSS 128/82 -82 -18 - 98% 97.9 patient is easily redirected but he's noncompliant with trying to get back into the other bed, patient seen multiple times trying to get into the bed and was redirected to his bed, patient does not understand that he just fell from the bed that he's trying to get into. Patient does have slip resistant socks. (LPN name redacted) No mention of Neuro checks were in the notes also no Neuro check sheet provided to the survey team. For the fall on 8/20/20, the facility submitted an SBAR/ change and condition form, Root cause analysis investigation, and a neuro check sheet. A nurses note dated 8/20/20 read: 8/20/20 at 11:31 AM resident observed sitting on the floor by his bed wearing his brief but no gown, resident states he was trying to get into the bathroom. No injury noted. Neuro checks started. VSS (vital signs stable) RP/NP notified. (LPN name redacted). The fall investigation again stated that the Resident is a high fall risk. The root cause analysis form stated Observed Resident sitting on the floor, in front of his bed. He said he fell trying to go to the bathroom. For the fall on 9/2/20 at 10PM, the facility submitted an SBAR/ change of condition form that read: Resident was restless most of the shift requiring continuous redirection. At 7 PM was ambulating in his room tripped and fell resulting in a laceration, contusion above the left eye and three skin tears to the left arm the resident was sent to the ER for evaluation. Record review revealed no nurses note in the chart for the fall or when he was sent out to the ER, however there is a note on his return from the ER 9/3/30 at 1:30 AM and it read as follows: Patient arrived back from (hospital name redacted) via stretcher and EMT 99.7-89-22-156/90-95% on RA. 4 sutures to laceration over left eye, swelling has nearly close the eye and bruising is dark. Pt. is alert and verbal with LOC (level of consciousness) consistent with baseline. Pupils equal round reactive to light with accommodation. Patient is walking and moving all extremities. Hand grasps are equal denies headache or nausea no vomiting or [MEDICAL CONDITION] activity observed patient does express memories of the fall RP/MD aware. (LPN name redacted) For the fall on 9/3/20 at 10:00 PM a nursing note read: Patient was constantly redirected and made aware of safety limitation for the first few hours of the shift. He would not stop exiting his room. Patient also would bend over to pick up things off the floor. Many times being a scuff mark on the floor tiles. Patient found in doorway seconds after falling. Patient landed on right side is causing a large abrasion to the upper right arm skin tear on right hand and hematoma on the right side of his forehead. Some bleeding from the hematoma was stopped with slight pressure for a few seconds. Initially patient did not complain of pain. Neurological assessment showed no abnormalities. After about 20 minutes the patient began to complain of severe pain in his shoulder and was requesting to go to the hospital. MD notified patient was sent to hospital name rejected for evaluation with a copy of meds, face sheet, bed hold policy, care plan. MD/ RP notified. (LPN name redacted) The facility submitted the investigation of the fall along with copy of Neuro checks started at 10:00 PM, after the fall. The facility also initiated 15 minute checks after the fall on 9/3/20. The neuro checks and 15 minute checks were signed off at 10:00 and 10:15 PM and then restarted at 3:00 AM (9/4/20) when the resident arrived back to the facility from the ER. For the fall on 9/4/20 at 6:00 AM, the nurse's note read: Patient found on floor in the hallway with head sutures over right brow intact however bleeding. Bleeding stopped with light pressure. Large skin tear to left arm. Patient's neck stabilized by hand support with a pillow and EMT transport was cold at patient side. Pupils equal round and reactive to light with accommodation. Patient would not stop attempting to get up initially and required constant verbal assurance and direction. 30 minutes prior resident name redacted awoke and was redirected with snacks. After eating snacks he fell asleep again less than five minutes prior to the fall patient was asleep in his bed witnessed by rider RP/MD notified of transferred to hospital name redacted picked up by EMT's via stretcher in route at this time 9/4/20 at 6:00 AM.(LPN name redacted). An interview was conducted on 9/25 at 4:07 PM with LPN A via telephone: LPN A was asked did the facility notify him that we would be calling he stated that they did because they can't find the Neuro check sheet that he did. LPN A said that Resident #1 had a fall on 9/2/20 and he broke his glasses but it as it turns out those weren't his glasses those were reading glasses he had bifocals. LPN A stated that, It was the worst night in my nursing career I had two residents that I sent out that we're desaturating due to COVID and Resident #1 kept falling. He also stated I did not witness the fall but I heard him fall. On the third I found him on the floor he had to be sent out to the emergency room Neuro checks re-started and I called the responsible party. The CT scan was negative and the x-ray of his arm was negative . He came back around 3:30 in the morning we resumed his 15 minute checks. He was last checked on at 5:30 then at 6:00 AM I went to get my med cart and I found him in the hallway. LPN A stated that he had filled out the 15 minute checks until he went to get his cart. The Resident went to theER on [DATE] at 6:00 AM and was admitted . LPN A also stated that the resident really needed a one to one but quite frankly we just didn't have the staff to do it. He stated there was 17 patients and one nurse and one CNA on the COVID unit that he was working on that night. After the interview with LPN A, a review of the 15 minute check sheet revealed that the Resident was last checked at 5:30 AM and then was found on the floor at 6:00 AM . There is no documentation of the Resident being checked at 5:45 AM. A review of the hospital records reveal the Resident was seen in the ER and admitted to the hospital for [DIAGNOSES REDACTED]. On 9/25/20 during the end of day conference the Administrator was made aware of the concerns and no further information was provided.

Based on resident interview, staff interview, facility documentation review, clinical record review, financial record review, and in the course of a complaint investigation, the facility staff failed to prevent misappropriation and exploitation of resident financial assets for 3 of 7 residents (Resident #6, #5, #3). Immediate Jeopardy for Residents #6 and #5 was called on 10/16/2019 at 3:43 PM. It was removed on 10/16/2019 at 4:30 PM. After removal, it was lowered to a level 3 isolated for Residents #6 and #5 The findings include: 1. The facility staff applied for and received representative payee status from Social Security without the permission or knowledge of Resident #6, who was his own responsible party. Because Resident #6 did not have access to his money, he lost his apartment and his furnishings. His situation resulted in psychological harm including humiliation embarrassment, fear, becoming homeless while legally blind. 2. For Resident #5, the facility staff made an unauthorized withdrawal from his personal fund account and failed to provide him with any financial accounting of this account. This situation induced ongoing fear and anxiety, feelings of helplessness, fear of identity theft, and inability to communicate with advocates, including family. He continues to have no access to his personal financial accounts. This situation created ongoing fear and anxiety causing psychological harm. 3. For Resident #3 the facility staff misappropriated the Resident's funds by applying to become representative payee for the Resident's Social Security Income, despite the Resident's Power of Attorney stating they did not authorize or desire this and the facility permitted multiple withdrawals from the Resident's account without sufficient supporting evidence. 1. Resident #6 was a [AGE] year old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 5/16/19 was reviewed. Resident #6 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. Resident #6 was coded as having no rejection of care, physical or verbal behavioral issues. He had impaired range of motion in both his upper, and lower extremities on the left side. He required the physical assistance of one person for bed mobility, transfers, walking, bathing, eating, dressing, toileting, and personal hygiene. Resident #6's care plan was reviewed. There was no documentation that he was a danger to himself or others. As his own responsible party, Resident #6 exercised his right to determine which outside appointments he would attend. An excerpt from the care plan read, wishes to stay in facility LTC (Long Term Care) .Diabetes Mellitus. Diabetes medication as ordered by doctor. Monitor/document for side effects .At risk for Falls r/t (related to) Gait/balance problems, Psychoactive drug use, Vision/hearing problems. Anticipate and meet the resident's needs .uses anti-anxiety medications r/t Anxiety Disorder. Monitor for side effects .uses antidepressant medication r/t Depression. Monitor/document side effects and effectiveness Q-SHIFT (EVERY SHIFT) .bladder incontinence r/t Impaired Mobility and vision. The resident's risk for [MEDICAL CONDITION] will be minimized .impaired visual function r/t [MEDICAL CONDITIONS] .ADL (Activities of Daily Living) self-care deficit r/t Impaired balance. Assist with ADLs as needed. On 10/9/19 a review was conducted of a complaint submitted to the State Agency. An excerpt read: the facility took his Social Security check without his permission .his scheduled discharge date was 6/14/19, the administrator had his clothes packed on 6/7/19 and ordered him to leave the facility in the rain .Resident alleges that he has been sleeping at Walmart and any other place that he can find. The Discharge Summary dated 6/7/19 was reviewed. There was no physician evaluation of discharge, no physician's signature, no medical status measurements, no nutritional status and requirements, no mental and psychosocial status, no list of medications, no reason for discharge, and no facility staff signature. On 10/9/19, a review of facility documentation was conducted, revealing 2 documents by the facility's attending physician. 1) 2/26/19. Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits. An excerpt read, Do you expect the patient to be able to manage funds in the future? No. 2) 5/7/19. Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest? Unsure. Record says he is legally blind. However he wants to manage his own finances. Do you expect the patient to be able to manage funds in the future? Yes. On 10/15/19 at approximately 12:22 P.M. an interview was conducted with the Interim Business Office Manager (Employee I). The regular Business Office Manager was unavailable, and not allowed to return to work due to the fact that she was being investigated due to 'financial issues in the Business office', according to the Senior Operations Director (Employee E). The Interim Business Office Manager was asked for a copy of Resident #6's signed Resident Trust Account Agreement and Beneficiary form. The form she submitted had Resident #6's name typed on it, but was not signed by him or any witnesses. Resident #6 had not authorized the facility to establish a Resident Trust Account, neither did he authorize the facility to be his Beneficiary. In addition, she submitted 2 letters from Social Security. One addressed to Resident #6 dated 4/1/19 read in part We are writing to tell you that we have information that shows you need help managing your money and meeting your needs. Because of this information, we plan to send your Social Security benefits to (name of facility). We will call this organization your representative payee. Another dated 6/28/19 which was addressed to the facility read in part, We have decided that it would be best for (name of Resident #6) to have his checks sent to him. The money you will need to return includes saved and invested benefits .interest earned . money you have left over from any checks we sent you .any checks you might receive after the date of this letter. On 10/16/19 from 10:10 [NAME]M. until 11:00 [NAME] M., a telephone interview was conducted with Resident #6, who gave permission to be on speakerphone with the entire survey team present. During the interview, Resident #6 related the circumstances of his discharge from the facility. Resident #6 often paused and cried during the interview. He stated that he was a veteran. Resident #6 was asked to describe the impact the discharge and losing control of his Social Security funds had on him. He stated, . I felt embarrassed, humiliated, it's not anger, it's you are afraid because I can't see. They can do anything to me. I don't have the resources, family or contacts. You become numb inside because you witness what's going on and they lie so fluently. Resident #6 stated that the facility Vice President had called him 2 times since the previous night (10/15/19) to invite him to return to the facility, because the administrator and Business Office Manager no longer worked at the facility. 'I said to the man, why would you invite me back to the alley where I was mugged? You caused me to lose my residence because I couldn't pay for my apartment, and lose everything in it'. They gave me my (MONTH) and (MONTH) Social Security checks back in June, but it was too late by then. I had lost everything. I'm still homeless. About a month ago, I ended up in the hospital I'm supposed to get an infusion every 6 weeks to stay alive. 2. Resident #5, a [AGE] year old male, was admitted to the facility on [DATE]. Clinical record review revealed that Resident #5 was his own Responsible Party. Resident #5 presented as alert and oriented to person, place, time, and situation and was able to converse easily. On 10/15/19 at approximately 11:00 AM, an interview was conducted with Resident #5 and he stated, I know I'm supposed to get $40 a month, I have never gotten anything, no money at all, I have no idea where my money has gone, they are stealing it all from me, nobody will even talk to me about it when I ask I came here with my cell phone and it was time for me to pay my phone bill but nobody here would listen that I needed my money for my phone bill, my phone service got cut off so I just gave my phone to my sister to keep because what was the point of having it here? It's just not right how I am treated, they ignore me. On 10/15/19 at approximately 1:00 PM, a copy of the Authorization and Agreement to Handle Resident Funds was provided and contained Resident #5's written signature. Additionally, a copy of the Resident Fund Management Service Statement for Resident #5 from the opening of his Resident Trust Fund to present was requested and received. There was a withdrawal on 10/17/18 for $12.00 with a notation Barbershop and a withdrawal on 4/12/19 for $15.00 with a reference # 1 noted. There were no other withdrawal entries other than Care Cost payments for the Facility room and board. Verification of authorization for the 2 withdrawals, $12.00 and $15.00, was requested and provided. On 10/15/19 at approximately 3:00 PM, an interview was conducted with the Interim Business Office Manager (Employee I) who confirmed there was no evidence that Resident #5 received any quarterly statements of his Resident Trust Fund since the opening of the account in (MONTH) (YEAR). Employee I also confirmed that authorization for withdrawal of $12.00 on 10/17/18 to the Barbershop was not sufficient because the Daily Report of Beauty Shop Charges dated 10/1/18 did not contain Resident #5's signature for payment authorization. She stated that in the event he could not sign, two witnesses would be required to sign on his behalf, however the verification did not contain two witness signatures for authorization either. On 10/16/19 at approximately 9:00 AM, a follow-up interview was conducted with Resident #5 who stated, I have made a lot of requests about trying to find out where my money is, I have never received any money or statements and I don't know anything about withdrawals in my account, I wanted money to pay my cell phone bill back last year but that never happened so I lost my cell phone service, no one cares .I finally received a copy of my account statement yesterday for the first time but it's not right and no one has bothered to go over it with me to answer my questions-they just dropped it off and said they will be around sometime later, there are several folks in here that they do the same thing to, it's just not right .I cannot even have what is supposed to be rightfully mine. Resident #5 stated, I have been a working man all of my life and I have always paid my bills and managed my money. I may not have had very much in my life but I worked long and hard for what I did have and I managed myself up to the point that I arrived here. When I came here, I agreed to allow them (the facility) to take my Social Security check to pay for my room but I have been asking to see my account for a long time, over a year, and nothing. I feel as though my identity has been stolen. I feel robbed. I feel like (S**T) every day. I am a victim of this system and nobody cares. It's on my mind every day, I can't stop thinking about it. I don't go out of my room anymore, I used to go outside but I don't go anymore. Immediate Jeopardy was called on 10/16/2019 at 3:43 PM The facility Removal Plan was submitted by the facility on 10/16/19 and verified as having been implemented. The Immediate Jeopardy was abated at 4:30 P.M. The plan read: 1. Resident #6 received a refund check on 6-4-2019 from the facility RFMS (Resident Funds Management System) account in the amount of $887.00, and a check from the operating account on 6-5-2019 for $847.00. The Regional Vice President of Revenue reviewed the statement with Resident #5 and provided his quarterly statement on 10/15/2019. Resident #5 will have a refund of $12.00, the check has been requested. 2. A review of residents' RFMS for current residents will be conducted by the Regional Director of Business Office Services (RDBOS) to ensure that residents signed agreements for the facility to become their representative payee. Review of current residents in house with RFMS accounts was conducted to assure the physician statements were accurately completed for those incapable of managing their own funds and Social Security check assignment. Noted discrepancies will be corrected immediately. Facility will pay restitution to those residents as deemed appropriate with regard to investigative findings. A review of current residents for misappropriation was completed by the interdisciplinary team on 10-16-2019. 3. A) Regional Vice President of Revenue conducted education with the facility Business Office Manager, Human Resources/Payroll, Admissions Coordinator, and Executive Director on 10/16/2019 to ensure understanding of the Center's policy and procedure for obtaining Representative Payee, application process, maintaining resident funds, banking system, and providing quarterly statements. Education was also provided on federal regulation 483.10(f) (10) regarding resident rights to manage their financial affairs, and the procedure for managing accounts if the resident chooses to deposit money in the RFMS. B) Executive Director will review Social Security check assignments for accuracy and completeness upon admission. C) Authorization to open an RFMS account will be reviewed by the Executive Director or Director of Nursing for accuracy prior to an account being opened. D) Quarterly statements will be issued to the resident of designated representative. A signed copy of in-house statements will be obtained as acknowledgement from all competent residents and filed with copies of mailed statements. E) Executive Director will review Physician/Medical Officer statement of patient capability to manage benefits with the Director of Nursing prior to request. Upon completion Executive Director will review and validate NO/NO prior to submission to become Representative Payee on behalf of the resident. Regional Vice President of Revenue will review compliance with processes weekly for 8 weeks, and then monthly for 4 months to ensure continued compliance. 4. Ad-Hoc QAPI held on 10-16-19 to review the deficient practice and changes to company policy BO-427. Findings will be reported to the Executive Director who will then report these findings to the QAPI monthly x 6 months for continued substantial compliance and/or revision. 3. For Resident #3 the facility staff misappropriated the Resident's funds by applying to become representative payee for the Resident's Social Security Income, despite the Resident's Power of Attorney stating they did not authorize or desire this and the facility permitted multiple withdrawals from the Resident's account without sufficient supporting evidence. Resident #3 was originally admitted to the facility on [DATE], with a readmission on 8-1-17, following a hospitalization . Resident #3 was discharged from the facility on 8-13-19. The Resident's [DIAGNOSES REDACTED]. The Resident's most recent (MDS) Minimum Data Set, was a discharge assessment, with an Assessment Reference Date of 8-13-19, and coded Resident #3 as being able to understand, and to be understood by others. She was coded as moderately impaired for daily decision making with poor decisions. The Resident was coded as having memory deficits, and was moderately cognitively impaired. The Resident required extensive assistance from staff for bed mobility, transferring, dressing and toileting. A review of the closed record was conducted. On 10-16-19 during a closed record review, it was revealed that Resident #3 had executed a durable power of attorney (POA) appointing her daughter as her authorized representative to act on her behalf prior to admission to the facility. On 12-28-16 during the admission process, Resident #3's daughter/POA signed pages 10 and page 12 of the admissions agreement indicating she did not want to open a Resident Trust Fund Account. Despite this request, the facility business office manager sent Resident #3's daughter/POA a letter on 3-15-17, along with a corrected patient trust account agreement asking her to sign to open an account, due to a cash payment being received. On 10-16-19 during a closed record review, it was also revealed that Resident #3's daughter/POA had signed page 19 of the admissions agreement on 12-28-16, stating I do not want my social security check assigned to (facility name redacted). Despite this request by Resident #3's POA, the facility staff completed an application to become Representative Payee for Resident #3's social security benefits on 12-29-16. The facility physician then completed on 1-5-17 a Physician's/Medical Officer's statement of patient's capability to manage benefits indicating that Resident #3 was unable to handle her financial affairs, making no reference to Resident #3's written POA executed 6-11-10 appointing her daughter to handle her financial affairs on her behalf, in the event Resident #3 was no longer able to manage her affairs herself. On 10-16-19 during the closed record review it was identified that from 6-20-18 until 9-4-19 there were a total of 4 communications found addressed to the facility (name redacted) on behalf of Resident #3. The first being that the Social Security Administration had received the application from the facility applying to be representative payee for Resident #3. On 10-16-19 during the closed record review it was identified that from 3-2-18 until 5-24-19 there were 8 cash withdrawals from Resident #3's Resident Trust Fund Account, which totaled $370. Each of these cash withdrawals contained illegible signatures, lack of 2 witnesses, or the Resident signed. Resident #3 had a [DIAGNOSES REDACTED]. On 10-16-19 at 6:52 PM during an interview with Employee J, the Regional Director of Business Office Services when asked about Resident #3's trust account, Employee J stated, I've looked at it, I know it's not good, signatures are not legible and there aren't two signatures. On 10/16/19 at approximately 3:30 PM a review was conducted of the facility policy titled Resident Trust Fund- Application for Representative Payee Status with a revision date of 6/28/19. The policy read, Upon notification from the Care Center's Executive Director, the Business Office Manager will initiate, complete, and mail the Request for Representative Payee application in a timely manner. This same policy, referenced above, further stated, The business office manager should file for Representative Payee in those cases where the resident is not capable of handling their own funds. This policy doesn't take into account or allow the Resident to allow their previously selected representative such as a power of attorney to manage their financial affairs on their behalf. The facility staff were made aware of the concern of the facility policy violating Resident #3's right to manage his or her financial affairs on the afternoon of 10-16-19. On 10-16-19 at approximately 6:00 PM, the facility staff made revisions to the facility policy titled Resident Trust Fund- Application for Representative Payee Status, and presented the survey team with the updated policy. The revisions included the regulation text which allows the Resident the right to manage their financial affairs and the facility to only apply for Representative Payee upon written request of the Resident. No further information was provided. COMPLAINT DEFICIENCY.

Based on resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to orient one of seven residents (Resident #6) to ensure a safe and orderly discharge, resulting in Immediate Jeopardy. Immediate Jeopardy was called on 10/9/19 at 2:30 P.M. It was removed on 10/10/19 at 11:45 [NAME]M. After removal, it was lowered to a level 3 isolated. The Findings Included: 1. Resident #6 was discharged on [DATE] against his will in an unsafe manner to an unknown location with an unknown individual. The facility failed to give him education and a glucometer to manage his medication, which included sliding scale insulin. The facility also gave the resident 50 Tablets of [MEDICATION NAME], which is a controlled narcotic. Resident #6 was a [AGE] year old who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 5/16/19 was reviewed. Resident #6 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. Resident #6 was coded as having no rejection of care, physical or verbal behavioral issues. He had impaired range of motion in both his upper, and lower extremities on the left side. He required the physical assistance of one person for bed mobility, transfers, walking, bathing, eating, dressing, toileting, and personal hygiene. Resident #6's care plan was reviewed. There was no documentation that he was a danger to himself or others. As his own responsible party, Resident #6 exercised his right to determine which outside appointments he would attend. An excerpt from the care plan read, wishes to stay in facility LTC (Long Term Care) .Diabetes Mellitus. Diabetes medication as ordered by doctor. Monitor/document for side effects .At risk for Falls r/t (related to) Gait/balance problems, Psychoactive drug use, Vision/hearing problems. Anticipate and meet the resident's needs .uses anti-anxiety medications r/t Anxiety Disorder. Monitor for side effects .uses antidepressant medication r/t Depression. Monitor/document side effects and effectiveness Q-SHIFT (EVERY SHIFT) .bladder incontinence r/t Impaired Mobility and vision. The resident's risk for [MEDICAL CONDITION] will be minimized .impaired visual function r/t [MEDICAL CONDITIONS] .ADL (Activities of Daily Living) self-care deficit r/t Impaired balance. Assist with ADLs as needed. On 10/9/19 a review was conducted of facility documentation, revealing 2 different Involuntary Discharge Notices that were given to Resident #6. The first one was a 5-Day Involuntary Discharge Notice dated 4/23/19. An excerpt read, This is to notify you that you will be transferred/discharged from our facility to SAFE L[NAME]ATION OF DISCHARGE BASED ON RESIDENT'S NEEDS, effective 4/30/19. You are being discharged because the health and safety of the resident, other residents or staff is endangered. The second Involuntary Transfer Discharge Notice was issued on 5/6/19. An excerpt read: This is to notify you that you will be transferred/discharged from our facility to SAFE L[NAME]ATION OF DISCHARGE BASED ON RESIDENT'S NEEDS, effective 6/6/19 You are being discharged because the health and safety of the resident, other residents or staff is endangered. Resident #6 appealed the decision but was still discharged . On the day of the discharge, at 6:12 P.M., an excerpt from the Social Service progress note read, 6/7/19. SW (social worker) reiterated today as guest discharge date . Resident again stated that his son will be here to pick him up on Friday of next week. SW stated that the ED (Executive Director) did not approve of that. ED requested we meet with the guest together to reiterate discharge will be today .attending this meeting was the ED, DON (Director of Nursing) Nurse Manager Central Supply Manager and guest Ed again informed guest that today is his discharge date and next Friday was not an option because guest does not meet criteria for LTC (Long Term Care). ED stated a taxi will be called and he will discharge at 1:30 P.M. When guest was approached later he was calling 911. Two officers arrived and spoke with resident. As a result per ED, guest was to exit the building at 4:05 P.M. and if not the officers would return to escort him off the property. Shortly after 4:00 P.M. a young man arrived to pick guest up. Guest was unable to pack all his belongings in the vehicle and stated he would come back tomorrow to gather the rest. While typing this note the same young (man?) that came earlier returned to gather the remainder of the item belonging to (Resident #6). On 10/10/19 at approximately 9:00 [NAME]M., an interview was conducted with the Director of Social Services (Employee P) in the conference room with another surveyor present. When asked about the circumstances of Resident #6's discharge, she stated, We have kept other people here many times until we could find a place to go. When we went up to speak to him he said he felt threatened. It was me, the ED and the Medical Supply guy, who is a very big guy. I didn't decide who was there. The ED asked the supply guy to come. When Employee P was asked if she had ever felt threatened by Resident #6, she said I didn't ever feel threatened by him He called me a few days after he left to ask for help regarding his medications. I told him that I didn't cover that area. I did not document, or follow-up with anyone at the facility regarding his request. There was no documentation that the facility provided Resident #6 with education or a glucometer so that he could safely self-administer physician ordered sliding scale insulin. The signed physician order [REDACTED]. Inject as per sliding scale: If 201-300 =2; 301 - 400 =4; 401-500 = 6;501-600 =call MD According to the Medication Administration, during the 7 day period prior to Discharge on 6/7/19, Resident #6's blood sugars ranged from 146 to 405, requiring various amounts of insulin. On 10/10/19, an interview was conducted with the Director of Nursing (Employee B) at approximately 10:00 [NAME]M. in the conference room with another surveyor present. She submitted the discharged Resident Medication Transfer Record and stated the Resident #6 was given the rest of his medications that were left in the medication cart. An excerpt read: [MEDICATION NAME] ([MEDICATION NAME]) 2 MG Tablets 1 Tab by mouth twice daily for anxiety. Narcotic. Quantity 50. [MEDICATION NAME] 100/ML Unit as per sliding scale subcutaneous before meals. Quantity 1. When asked how Resident #6 would be able to determine how much insulin to administer, the DON stated that she didn't know. She was asked if it was normal practice for the facility to be unaware who the resident left with and where he went. The DON stated that if she had done the discharge, I would ask if they had a glucometer at the time. He could bottom out-blood sugar drop. He could die. The nurse should go over the parameters with the resident. When asked if it was safe to give a homeless resident 50 [MEDICATION NAME] tablets with no way to secure them, the DON stated I told you everything I know. We should have documented who he went with on the Discharge Summary and made sure he signed in the right place. I think nurses should ask about discharging residents with [MEDICATION NAME]. When asked about the importance of providing residents with education, a glucometer, and instructions prior to discharge, the DON stated, So they will have an understanding of what's going on or how their stay was. The Discharge Summary dated 6/7/19 was reviewed. There was no physician evaluation of discharge, no physician's signature, no medical status measurements, no nutritional status and requirements, no mental and psychosocial status, no list of medications, no reason for discharge, and no facility staff signature. The facility policy on Transfer/Discharge Notification & Right to Appeal, dated 3/26/18 was reviewed. An excerpt read, Transfer and discharges of residents initiated by the center will be conducted according to Federal and/or State regulatory requirements. The center must permit each resident to remain in the center, and not transfer or discharge the resident from the center unless .The center may not transfer or discharge the resident while the appeal is pending, when a resident exercises his or her right to appeal a transfer or discharge notice .unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the center. The center must document the danger that failure to transfer or discharge would pose. On 10/16/19 from 10:10 [NAME]M. until 11:00 [NAME] M., a telephone interview was conducted with Resident #6, who gave permission to be on speakerphone with the entire survey team present. When asked to describe the circumstances of his discharge from the facility, he stated, ( Interim Business Office Manager- Employee I. (she had not yet been designated as the Interim Manager as of the date of the discharge on 6/7/19)) came up to my room and said she was going to call the police on me. She said how disgusting I was. She said, You better believe I'm gonna call the police and get you out of here. The Director of Nursing (Employee B) had a letter. The Nurse Manager (Employee Q) read it to me. It said I was a danger to myself and others Later that day, the housekeeping guy was walking up the hall so he walked up on me. He was in my personal space, one foot in front of me, I couldn't move my rollator. He said I was too loud and disrespectful to staff. I told him to move out of my way. The Unit Manager (Employee Q) encouraged me to go downstairs and report it. I went to Human Resources. The next thing I knew (Unit Manager Employee ) calls me into her office and read me a letter. She said it came from the corporate office saying that I had to vacate. Resident #6 often paused and cried during the interview. He stated that he was a veteran. Resident #6 was asked to describe the impact the discharge had on him. He stated, When I was told this by the housekeeping guy, I had to get out in the rain, I had nowhere to go so I slept at Walmart that night. I felt embarrassed, humiliated, it's not anger, it's you are afraid because I can't see. They can do anything to me. I don't have the resources, family or contacts. You become numb inside because you witness what's going on and they lie so fluently About a month ago, I ended up in the hospital I'm supposed to get an infusion every 6 weeks to stay alive. According to hospital records dated 8/16/19, Resident #6 was taken to the emergency room via ambulance. He presented with Abdominal Pain level 10, Altered Mental Status, and Weakness. An excerpt read, Received intravenous tissue plasminogen activator. Unilateral weakness, Patient paged as a stroke alert. admitted to the Intensive Care Unit. Resident #6 was discharged to a long term care facility on 8/22/19. Immediate Jeopardy was called on 10/9/19 at 2:30 P.M. The facility Removal Plan was submitted by the facility on 10/10/19 and verified as having been implemented. The Immediate Jeopardy was removed on 10/10/19 at 11:45 [NAME]M. The removal plan read: 1. Resident #6 was discharged from the facility on (MONTH) 7, 2019 accompanied by a male friend and did not disclose the location he was going to. 2. Residents that reside in the facility have the potential to be affected. The facility Social Worker has conducted a quality review of residents with pending plans to discharge. The facility Social Worker and Charge Nurse will ensure that arrangements are made for a safe discharge to include education on safe and proper medication administration of narcotics and insulin, a safe discharge location, and given proper discharge instructions. 3. The Regional Director of Clinical Services will educate the licensed nurses and IDT staff regarding the discharge process to include: arrangements are made for a safe discharge to include education on safe and proper medication administration to include but not limited to narcotics and insulin, facility will have a safe discharge location, and the resident and or responsible party will be given proper discharge instructions. Current Executive Director, Director of Nursing, Social Services, licensed nurses were educated as of midnight on 10-9-19. Licensed nursing staff will not work until educated. 4. The interdisciplinary team will review residents with plans to discharge weekly in morning meeting to ensure discharge arrangements have been made to detail discharge location, transportation, medication management, home health services, treatment, and follow-up appointment needs of resident as necessary. 5. Adhoc QAPI meeting held with the IDT on 10/9/2019 at 4:15 P.M.

Based on Resident interview, staff interview, facility documentation and clinical record review the facility failed to ensure the environment was free of accident hazards for 1 Resident (Resident # 122) in a survey sample of 46 Residents resulting in harm. For Resident #122, the facility failed to provide a safe raised commode seat resulting in a fall requiring hospitalization for 3 fractured ribs. Resident #122, a [AGE] year old woman, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent (Minimum Data Set) MDS (a screening tool) had the Resident coded as having a (Brief Interview of Mental Status) BIMS score of 15 indicating no cognitive impairment. Resident #122 was coded as needing physical assistance of 1 staff member for all transfers and toileting. On 10/3/18 a review of the clinical record for Resident # 122 was conducted and it was found that on 8/30/18 at 11:45 PM, Resident #122 yelled out and was found on the floor of her bathroom (an unwitnessed fall) resulting in serious injury. According to the fall investigation dated 8/30/18 the Resident was assessed by nursing staff and denied any unusual pain. She was assisted back to her wheelchair where she stayed throughout the night because she refused to get into bed. According to the Medication Administration Record, [REDACTED]. In the morning of 8/31/18, Resident #122 was sent out to the emergency room for complaints of Shortness of breath and rib pain and was found to have 3 fractured ribs. On 10/04/2018 at 10:35 AM during an interview with Resident #122 she stated, They know I take myself to the toilet, they never want to help if you put the call light on someone comes in turns it off and tells you someone else will be in to help you soon. Then they never come back so you put the light on again, but if that toilet wasn't wobbling I would not have fallen. She also stated, They have fixed it a few times, if you call that fixing it. According to facility documentation in the Maintenance Log Book the Raised commode seat was fixed in room [ROOM NUMBER] (Resident #122's room) on 8/22/18. A raised commode seat is a device that fits over the toilet which raises the toilet seat about 5 inches and is clamped to the toilet to keep it in place. On 10/4/18 at 6:30 PM, during an interview with Employee C, a maintenance tech. Employee C stated that he tightened the toilet seat several times. He stated that Resident #122 would stop him in the hall and ask him to tighten the toilet seat. On 10/4/18 at 6:40 pm, in an interview, Administration D (the former administrator) stated that Maintenance was aware that the toilet seat was not fitting properly and that it had been adjusted several times. Administration D stated they educated Maintenance on 8/31/18 that if a piece of equipment has to be repaired several times then it should probably be removed until it can be replaced. Administration D stated the raised commode seat was removed after the fall on 8/30/18 but the facility could provide no evidence that the seat was ever removed on 8/30/18. However, according to the Maintenance Log the raised commode seat was not removed until 09/04/18 when the Resident returned from the hospital and once again complained the raised seat was not sturdy. On 10/4/18 at 6:40 PM during interview Administration D and Employee C both stated they did not know how the raised commode seat ended up back in the Resident's bathroom. On 10/4/18 an observation showed the raised seat was replaced with a bedside commode frame with handrails, placed over the existing toilet to add height but also to add stability with the handrails and legs that have nonskid tips that reach the floor. There was no further information provided.