**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Resident 1 and 2) when on 10/22/2023, at 3:45 p.m., Resident 1 and Resident 2 punched each other. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility and resulted in Resident 1 having facial bruises, a facial cut, and he was feeling anxious and not safe in this facility. Resident 2 had a skin tear on his forehead and a skin tear on his upper left cheek. Findings: A review of Resident 2's admission Record indicated the facility initially admitted Resident 2 on 3/30/2023 with a readmission date of 8/17/2023. Resident 2's diagnoses included sepsis (the body's extreme response to an infection), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). According to a review of the Initial History and Physical, dated 8/18/2023, Resident 2 had the capacity to understand and make decisions. A review of the care plan dated 8/21/2023 indicated Resident 2 had a potential for aggression related to anxiety, with episodes of screaming and yelling. The care plan goal indicated Resident 2 would verbalize understanding of need to control abusive behavior. The care plan interventions indicated to assess resident's coping skills and support system, and when resident becomes agitated to intervene before agitation. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 9/29/2023 indicated the resident had delusions (misconceptions or beliefs that are firmly held, contrary to reality). According to a review of the Situation, Background, Assessment, Recommendation communication form (SBAR), dated 10/23/2023 at 11:29 a.m., Resident 2 had a physical and verbal altercation with Resident 1. Resident 1 claimed that Resident 2 unplugged his TV without his permission, started a verbal altercation, then both residents started punching each other. A review of Resident 2's Skin Evaluation, dated 10/23/2023 at 11:31 a.m., indicated a skin tear of 2 cm by 0.1 cm on the left side of the forehead and a skin tear of 2.2 cm by 0.1 cm on the upper left cheek. A review of Resident 2's Order Audit Report, dated 10/23/2023 at 3:04 p.m., indicated open skin on the left upper cheek and to clean the skin with Normal Saline (NS), pat it dry, and apply an antibiotic cream daily for 14 days. A review of the Treatment Administration Record dated 10/24, 10/25, 10/26 and 10/27/2023 indicated Resident 2 received open skin treatments on the upper left cheek and left side of the forehead. A review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 1/14/2020 with a readmission date of 9/24/2023. Resident 1's diagnoses included sepsis (the body's extreme response to an infection), major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and opioid abuse (compulsive urge to use opioid drugs [class of drugs that derive from the opium poppy plant], even when they are no longer required medically). A review of the MDS dated [DATE], indicated Resident 1's cognitive skills (ability to understand and make decisions) were intact and required supervision or touching assistance for transferring, oral and toileting hygiene, and upper body dressing. The MDS indicated Resident 1 was not walking and was used a wheelchair as a mobility device. A review of Resident 1's Skin Evaluation, dated 10/23/2023 indicated a skin tear of 0.2 centimeters (cm - unit of measurement) by 1.5 cm on the face. A review of Resident 1's Order Audit Report, dated 10/23/2023 at 6:02 p.m., indicated open skin on the left cheek and to clean the skin with Normal Saline (NS), pat it dry, and apply bacitracin (an antibiotic used to prevent bacterial infection) ointment daily for 14 days. According to a review of Resident 1's Telemedicine Visit (using telecommunications technologies to support the delivery of all kinds of medical, diagnostic and treatment) dated 10/27/2023, Resident 1 was seen for a psychiatric evaluation. The psychiatric evaluation indicated that after the physical altercation with Resident 2, Resident 1 was in physical pain from the incident, verbalized feeling anxious, and was willing to try medication for anxiety. A review of the Physician's Order dated 10/27/2023 at 8:52 p.m., indicated Resident 1 was prescribed Ativan (medication used to treat anxiety) 0.5 milligrams (mg - unit of measurement) taken every six hours as needed for anxiety for 14 days. A review of the Medication Administration Record (MAR) indicated Resident 1 received Ativan 0.5 mg every day from 11/3 through 11/10/2023. During an observation on 11/29/2023 at 12:30 p.m., Resident 1 was in his room, sitting in the wheelchair eating lunch. During a concurrent interview Resident 1 stated his old roommate (Resident 2) was moved to another room because they had an altercation. During an interview on 11/29/2023 at 4:05 p.m., Resident 1 stated that in the middle of the day on 10/22/2023 Resident 2 attacked him. Resident 1 stated that Resident 2 unplugged his TV without asking, he then told Resident 2 to not come near his stuff after which Resident 2 hit him on the cheek, and then they both started punching each other. Resident 1 stated that at the time of the altercation he was sitting in a wheelchair and Resident 2 was standing. Resident 1 stated that as a result of this altercation he received facial bruises, a facial cut, and he was feeling anxious and not safe in this facility. During an interview on 11/29/2023 at 4:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that on 10/22/2023 around 3:45 p.m., he was in another room when he heard screaming from Resident 1's room. LVN 1 stated he went to Resident 1's room and saw that Resident 1 and Resident 2 were fighting with each other. LVN 1 stated that he separated the residents immediately and reported the incident to Director of Nursing 2 (DON 2). During an interview on 11/30/2023 at 4 p.m., the Assistant Director of Nursing (ADON) stated physical abuse happened between Resident 1 and Resident 2, and that it should not have occurred according to the abuse policy and regulations. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation Prevention, revised April 2023, indicated residents have the right to be free from abuse, this includes physical abuse. The policy indicated the facility abuse prevention program consists of a facility wide commitment and resource allocation to support other residents and identify and investigate all possible incidents of abuse, neglect and mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an environment that was free of accident hazards for two of seven residents (Resident 24 and Resident 33) by failing to: 1. Ensure Certified Nurse Assistant 9 and 10 (CNA 9 and CNA 10) checked the integrity of the Hoyer lift (an equipment used by caregivers to safely transfer patients) sling and if the size was appropriate prior using it to transfer Resident 24 from a wheelchair (WC) to a bed on 10/5/2023 in accordance with the facility's policies and procedures (P&P) titled, Lifting Machine, Using a Mechanical, revised 9/2023, and the manufacturer's undated instruction manual on Hoyer lift sling. Resident 24 weighed 426 pounds at the facility. On 10/5/2023, the Hoyer lift sling snapped (break suddenly and completely) when CNA 9 and CNA 10 were transferring Resident 24 from WC to a bed. Resident 24 fell four feet from the Hoyer lift to the floor. These deficient practices resulted in Resident 24 was transferred to a general acute care hospital (GACH) for further evaluation and management. Resident 24 was diagnosed with right femur (thigh bone) fracture (break in a bone) and was treated for pain. Resident 24 had severe anxiety and fear secondary to the circumstances surrounding her fall incident on 10/5/2023. 2. Resident 33 was not allowed to have an extension cord wrapped around the upper siderails of the bed, and an electrical fan and phone charger connected to a power strip and placed at the foot of Resident 33's bed in accordance with the facility's P&P titled Maintenance Service dated 12/2022, and P&P titled Fire and Safety Prevention dated 12/2022, indicated. The deficient practice increased the risk for accidents related to falls, fire and safety hazards, and death for Resident 33 and all residents, staff, and guests in the facility. Findings: 1. A review of Resident 24's admission record indicated the facility originally admitted Resident 24 on 4/20/2023 with diagnoses that included but were not limited to morbid obesity (a weight that is more than 100 pounds above a person's ideal body weight), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow) and gait and mobility abnormalities (a change in walking patterns). A review of Resident 24's Care Plan, initiated 4/21/2023, indicated Resident 24 had an ADL self-care performance deficit related to impaired balance, limited mobility, limited range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) and a musculoskeletal impairment. The interventions indicated Resident 24 required a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) with two person assist for transfers, the resident required assistance by one staff to turn and reposition in bed every two hours and as necessary and that Resident 24 required one staff to assist her with showering. A review of Resident 24's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 7/27/2023 indicated Resident 24 was cognitively intact. The MDS indicated Resident 24 required extensive staff assistance to total dependence with surface transfer, bed mobility, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. The MDS further indicated Resident 24 had functional limitation (limitations due to the illness, as people with a disease may not carry out certain functions in their daily lives) impairment in ROM in both of her legs. A review of the facility's Hoyer Lift (mechanical lift) Maintenance Checklist, for the months of 8/2023, 9/2023 and 10/2023, the check lists indicated the facility's Maintenance Director (MNTD) inspected the Hoyer lift and its accessories (a finished device that is intended to support and or supplement the performance of one or more parent device[s]) for any sign of wear monthly. However, the Hoyer lift check list did not indicate the dates the Hoyer lift check was completed. A review of Resident 24's Weights and Vitals Summary, indicated that on 10/4/2023, Resident 24 weighed 426 pounds. A review of Resident 24's Progress Note dated 10/5/2023, indicated that on 10/5/2023 at around 5:50 PM, Licensed Vocational Nurse 4 (LVN 4) heard screaming sound/voices. LVN 4 went to Resident 24's room and saw Resident 24 on the floor. Resident 24 was on top of the Hoyer lift. LVN 4 interviewed CNA 9 and CNA 10 who claimed that as they were transferring Resident 24 from a WC to bed via a Hoyer lift when the Hoyer lift sling snapped. The progress note further indicated 911 (a telephone number used to reach emergency medical, fire, and police services) was contacted. The paramedics (a team of trained staff who provide emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived and it took six people to transfer Resident 24 from the floor to the gurney chair (comfortable, all-purpose device that can transform from flat form to chair in seconds). A review of Resident 24's after Fall Care Plan, initiated 10/5/2023, indicated that on 10/5/2023, Resident 24 fell while being transferred from a Hoyer lift when the right and left sides of the Hoyer lift sling snapped. Resident 24 fell onto her right side and landed on top of the Hoyer lift. The goal included Resident's pain will resolve without complication by the review date of 10/25/2023. The interventions included to determine and address causative factors of Resident 24's fall. A review of Resident 24's SBAR (Situation, Background, Assessment, Recommendation - a tool used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) Communication form dated 10/5/2023, indicated CNA 9 and CNA 10 used a Hoyer lift to transfer Resident 24 from WC to bed. The SBAR indicated CNA 9 and CNA 10 inspected and properly placed the Hoyer lift and Hoyer sling prior to transferring Resident 24. The SBAR indicated while transferring Resident 24, the right lower sling loop snapped and then the left lower sling loop also snapped. The SBAR indicated Resident 24 fell to the floor on her right side and landed on top of the Hoyer lift. A review of Resident 24's Physician Orders dated 10/5/2023, indicated to transfer Resident 24 to GACH via emergency services after a fall. A review of the facility's Notice of Transfer/Discharge Form, dated 10/5/2023, indicated Resident 24 was transferred to a GACH because Resident 24's needs could not be met in the facility. A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 10/5/2023, indicated Resident 24 was brought in by ambulance. Resident 24 sustained an injury to her right hip and knee after falling from mechanical lift equipment due to equipment malfunction. The ED notes indicated Resident 24 said she was being lifted back to her bed using mechanical lift and the equipment reportedly snapped and the lift [Hoyer] dropped her. The ED notes further indicated Resident 24 complained of pain in her right hip radiating down her right leg and knee. Resident 24 was having more pain during ROM of the leg right leg. A review of Resident 24's GACH computerized tomography scans (CT scans - a series of X-ray images taken by computers to create more detailed images of bones, blood vessels, and tissues inside the body) report dated 10/5/2023, indicated a transverse (straight across) and impacted (a break where the ends are driven into each other) femur (thigh) fracture was partially visualized. A review of Resident 24's GACH Medication Administration Record (MAR) for the month of 10/2023, indicated that on 10/5/2023, Resident 24 received intravenous (IV - inside a vein) Dilaudid (a strong opioid medication to treat severe pain) one milligram (mg - unit of measurement) at 7:54 PM and 0.5mg at 9:03 PM while in the emergency room. A review of Resident 24's Progress Note dated 10/6/2023 at 12:06 AM, indicated CNA 9 and CNA 10 were transferring Resident 24 from a WC to bed using a Hoyer lift. The progress note indicated while transferring Resident 24, the right lower sling loop snapped and then the left lower sling loop also snapped. The progress note indicated Resident 24 fell to the floor on her right side and landed on top of the Hoyer lift. A review of Resident 24's GACH History and Physical (H&P), dated 10/6/2023, indicated Resident 24 was admitted to the GACH on 10/5/2023 due to a mechanical fall and with a possible femur fracture. A review of the Orthopedic (a branch of medicine that treatments disorders or injuries of the bones, joints, and associated muscles) Consultation Note dated 10/6/2023, indicated Resident 24 had right femur fracture, was not a surgical candidate and to initiate a knee immobilizer (a removable device that maintains stability). It also indicated Resident 24 weighed 194.8 kilograms (437.36 pounds). A review of Resident 24's GACH Nursing Progress Note dated 10/10/2023, indicated Resident 24 said she had anxiety (nervousness/restlessness) at night regarding her pending transfer back to the facility. The progress notes further indicated Resident 24 had suicidal thoughts because she felt pushed to transfer back to the same facility she came from before hospitalization. A review of Resident 24's Psychiatric (A branch of medicine that specializes in mental health, including substance use disorders) Consultation Note dated 10/12/2023, indicated Resident 24 sustained a fall while being hoisted out of the shower and fell four feet onto the floor on 10/5/2023 and sustained a femur fracture. The psychiatric note also indicated Resident 24 was alleged to have suicidal thoughts and the consult was to assess Resident 24's safety. The psychiatric note also indicated Resident 24 had severe anxiety and fear secondary to the circumstances surrounding her fall. The psychiatric note indicated Resident 24's diagnosis was moderate major depression and psychotropic medications ( medication affecting the mind or mental processes) would be initiated. During an observation in the conference room on 10/17/2023 at 3:40 PM, the facility's blue sling used to transfer Resident 24 on 10/5/2023 was inspected. The right side loop of the Hoyer lift sling was completely separated (broken off) from the rest of the sling mesh. The left side loop of the Hoyer lift sling was broken/torn apart. The blue Hoyer lift sling was worn out with ripped in the material on all four corners around where the straps are sewn onto the sling. Also, there were two holes observed in the Hoyer lift sling mesh. During an interview on 10/17/2023 at 3:47 PM, CNA 9 stated on 10/5/2023 around 5:45 PM or 5:50 PM, he and CNA 10 were transferring Resident 24 back to bed with a Hoyer Lift. CNA 9 stated when they [CNA 9 and CNA 10] lifted Resident 24, the Hoyer lift sling loops ripped on the right side first and then the left side also ripped. CNA 9 stated Resident 24 fell landed on her heels first and then on her left hip. CNA 9 stated Resident 24 was shouting and complaining of pain on her right side from the knee to her hip. CNA 9 stated at the time of the fall, Resident 24's weight was probably over 400 pounds. CNA 9 stated when he saw the sling afterward after Resident 24's fall, he asked CNA 10 why she chose the blue Hoyer lift sling. CNA 9 stated CNA 10 replied the laundry staff gave her [CNA 10] the Hoyer lift sling because it was the only one available. CNA 9 stated the facility had a mixture of new and old Hoyer lift slings. CNA 9 stated the Hoyer lift sling used on Resident 24 was in was an older one. CNA 9 further stated he was not trained on how to differentiate which Hoyer lift sling was appropriate to use for a resident. CNA 9 further stated he did not check/inspect the integrity of Hoyer lift sling prior to using it on and transferring Resident 24 because it was already on the WC and under Resident 24. During a concurrent interview and observation with CNA 9 on 10/17/2023 at 4:37 PM, the blue Hoyer lift sling CNA 9 and CNA 10 used to transfer Resident 24 was inspected. CNA 9 stated, this was the sling that was in use when Resident 24 fell. CNA 9 stated the Hoyer lift sling did not have a tag/label to guide staff on the maximum weight capacity. CNA 9 further stated the Hoyer lift sling shows areas of wear around the straps (loops) and holes in the sling mesh and would not have used the blue Hoyer lift sling because it would probably drop Resident 24. When asked who maintains the slings, CNA 9 stated, I do not know who is responsible for ordering a new sling but probably maintenance. CNA 9 further stated the facility should check the Hoyer lift slings and change them out more often because a resident could fall which could lead to a fracture and death. During a telephone interview with MNTD on 10/18/2023, MNTD stated he monitors the Hoyer lift device and Hoyer lift slings monthly. MNTD stated most staff verbally communicate with him regarding concerns related to the Hoyer lift slings. MNTD further stated staff need to check the Hoyer lift slings tag/label to beware of weight capacity and look/inspect for any rips prior to using on a resident. MNTD stated the Hoyer lift sling should only be used if the weight capacity is indicated. MNTD stated he removes all Hoyer lift slings without tags and notifies the facility's administration. MNTD further stated laundry staff are not responsible to inspect Hoyer lift slings. MNTD further stated Hoyer lift slings should be inspected prior to use in order to prevent falls. During an interview with Laundry Attendant 1 (LNDRY1) on 10/18/2023 at 9:38 AM, LNDRY1 stated she washes the Hoyer lift slings, air dries them, and checks them to make sure no holes present in sling mesh. LNDRY1 stated Hoyer lift sling cannot be used if they look old. LNDRY1 further stated the nurses requests, visually checks for integrity and for size (small or large). LNDRY1 stated nurses are knowledgeable to determine which Hoyer lift sling is appropriate for a resident. During a telephone interview with CNA 10 on 10/18/2023 at 3:02 PM, CNA 10 stated Resident 24 needed to shower but the Hoyer lift sling that Resident 24 normally uses was not available. CNA 10 stated she went to the laundry room and the laundry attendant told CNA 10 that he only had two Hoyer lift slings. CNA 10 asked for the largest Hoyer sling the laundry attendant had. CNA 10 stated she checked the Hoyer lift sling to make sure it was not ripped. CNA 3 stated she transferred Resident 24 to a WC so Resident 24 could take a shower. CNA 10 stated she asked CNA 9 to assist her transfer Resident 24 back to bed using the Hoyer lift after Resident 24 was done taking a shower. CNA 9 stated as CNA 9 and CNA 10 lifted Resident 24 up and off the WC and forward towards the bed using the Hoyer lift, the right side of the Hoyer lift sling snapped followed by the left side and Resident 24 fell. CNA 10 further stated she checked the sling prior to transferring Resident 24 from the bed to WC but did not recheck the sling before transferring the resident from the WC and to bed. CNA 10 stated the facility trained her how to sit a resident in the Hoyer lift sling and which loops to use. CNA 10 stated, When we have heavy patients, they [patients/residents] would have their own Hoyer lift sling. CNA 10 stated the hoyer lift sling used on Resident 24 was an old sling purchased before 3/2023 by the facility's previous owner. During an interview on 10/18/23 at 4:21 PM, LVN 4 stated she heard Resident 24 and entered Resident 24's room after Resident 24 fell. LVN 4 stated Resident 24 was screaming out in pain and told LVN 4 that she fell from the Hoyer lift. LVN 4 stated the CNAs should inspect Hoyer lift slings for tears before use because tears could lead to the Hoyer lift sling ripping and the patient [resident] could fall and get hurt. During a concurrent interview and inspection with Director of Staff Development (DSD) on 10/20/23 at 9:56 AM, the Hoyer lift sling that was in use when Resident 24 fell, was inspected. The Hoyer lift sling had four straps with three loops per strap. All four straps and loops appeared discolored and frayed exposing thread like material with signs of wear and tear. The second loop on the strap to Resident 24's right leg, completely broke and separated from the sling into two separate pieces. The middle loop on the strap on Resident 24's left leg broke in one side of the strap. DSD stated Resident 24 could not bear weight on her legs and that the Hoyer lift was used for transferring Resident 24 for safety. DSD further stated, the laundry attendant must make sure there is a tag on sling so that they know if it [Hoyer lift sling] is safe. If we do not know the weight capacity of a Hoyer lift sling, then we do not know if it [Hoyer lift sling] is safe to use on the resident. The sling could break if it is not appropriate for the patient [resident]. During a concurrent interview and inspection with the Director of Nursing (DON) on 10/20/23 at 3:01 PM, the blue sling used to transfer Resident 24 when she fell was inspected. The DON stated staff LVN 4 told him that the Hoyer lift sling broke while transferring Resident 24 back to bed after shower because the Hoyer lift sling loops broke. The DON responded, I do not know when asked how old the Hoyer lift sling used on Resident 24 was. The DON also stated the sling could hold 500 to 600 pounds but did not know for sure because the Hoyer lift sling did not have a tag. The DON also stated he did not know the Maintenance Director's process for checking/inspecting the Hoyer lift sling. The DON stated CNAs should not use a Hoyer lift sling, if they do not know how much it can hold because we are dealing with the safety of the resident. During an interview with the Administrator (ADMIN) on 10/22/2023 at 10:41 AM, the ADMIN stated on 10/5/2023, she was told that Resident 24 fell. The ADMIN stated she went to Resident 24's room and saw Resident 24 on the floor and was lying across the legs of Hoyer lift. The ADMIN stated Resident 24 was screaming and saying, everything hurts. ADMIN stated the paramedics went to facility and transferred Resident 24 to a GACH. The ADMIN stated at the time of the fall, Resident 24 weighed around 420 pounds. A review of the facility's P&P titled Falls and Fall Risk, Managing, revised 3/2023, indicated, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls included lower extremity weakness and functional impairments. Medical factors that contribute to the risk of falls included balance and gait disorders., as part of the initial assessment; the licensed nurse will help identify individuals with a history of falls and risk factors for subsequent falling. A review of the facility's P&P titled, Lifting Machine, Using a Mechanical, revised 9/2023, indicated, the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instruction. The staff should measure the resident for proper sling size and purpose, according to the manufacturer's instructions and select a sling bar that is appropriate for the resident's size and the task. A review of the facility's P&P titled, Safe Lifting and Movement of Residents, revised 7/2023, indicated, in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. A review of the facility provided Drive DeVilbiss Health Care's Levantar and Gravis Floor Lifts, instruction manual indicated, Drive DeVilbiss Healthcare recommends regular inspection and maintenance, and the sling should be examined daily for wear or fraying, if any, to not use. To only use Drive DeVilbiss branded slings, always check the sling is suitable for the particular resident and is of the correct size and capacity, never use a sling which is frayed or damage and when the resident is two inches above the lifting surface to check all sling connection points to ensure all are secure. A review of the facility's undated in-service titled, Hoyer Lift Transferring, conducted by DSD, indicated the objective was to understand the proper way of using the Hoyer lift by knowing the process, materials needed and performing with safety precautions to prevent an injury from occurring. The Inservice indicated to seek a second health care worker for assistance if needed, and how to position the resident's bed and how to place the resident into the sling. The in-service had instructions on how to attach the hooks on the strap to the holes in the sling, to ensure the resident's safety. 2. A review of Resident 33's admission record indicated the facility admitted the resident with diagnoses that included stroke affecting the left side of the body and blindness in the right eye. A review of Resident 33's MDS dated [DATE], indicated Resident 33 was cognitively intact. During a concurrent observation and interview on 10/16/2023 at 9:31 AM, Resident 33 was observed in bed and an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip. Also observed, was a black fan that was plugged into the power strip along with a cellular phone charger at the foot of Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. Resident 33 was asked about the extension cord wrapped around the upper side rails, power strip, and fan and stated, staff does that because I get hot. During a concurrent observation and interview Licensed Vocational Nurse 1 (LVN1) on 10/16/2023 at 9:36 AM, an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip. Also observed, was a black fan that was plugged into the power strip along with a cellular phone charger at the foot of Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. LVN1 confirmed and stated, not supposed to be like that for safety reasons because of electrical fire and safety hazard . LVN1 stated the orange extension cord, and the rectangular power strip will be removed. During a follow up observation on 10/18/2023 at 10:10 AM, Resident 33's room had an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip, and black fan still on the bed on Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. During a follow up observation and interview on 10/18/2023 at 10:52 AM, Resident 33's room had an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip, and black fan still on the bed on Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. When asked about the orange extension cord, power strip, and fan, Certified Nursing Assistant 3 (CNA3) stated, The fan is always there, [Resident 33] wants it there to charge her phone and to plug in all her devices. CNA3 did not know if Resident 33 was allowed to have the orange extension cord, rectangular power strip, and black fan. During a follow up interview on 10/18/2023 at 12:33 PM, LVN1 stated CNA3 informed LVN3 about the interview with the surveyor and the extension cord, power strip, and fan were removed, and maintenance to mount the fan to prevent fall and fire hazards. During an interview on 10/20/2023 at 4:12 PM, the Director of Nursing (DON), stated residents are required to have a power strip that was compliant with safety regulations. The DON stated maintenance should supply residents with power strips that compliant with safety regulations. The DON stated Resident 33's fan will be placed on a table to prevent fire hazards. A review of a facility's P&P titled Maintenance Service dated 12/2022, indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The policy indicated functions of the maintenance director included but were not limited to Maintaining the building in good repair and free from hazards. A review of a facility's P&P titled Fire and Safety Prevention dated 12/2022, indicated 1. Fire prevention is the responsibility of all personnel, residents, visitors, and the general public. 2. Whoever identifies a fire hazard. or other conditions that could develop into a fire hazard, must report the situation to the department director or Maintenance Director as soon as practical.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with hemiplegia (paralysis of one side of the body), and reduced mobility, received two or more-person physical assistance with transfer, per the comprehensive assessment. Resident 1 was solely transferred from wheelchair to bed by Certified Nursing Assistant 1 (CNA) on 8/18/2023. This deficient practice caused Resident 1 to complain of severe pain to the right leg on 8/18/2023, requiring transfer to the general acute care hospital (GACH) 1 where Resident 1 was diagnosed with a distal femoral fracture (break in thigh bone just above the knee joint) and treated with a soft cast. Resident 1 complained of unrelieved pain, was transferred to GACH 2 and underwent an open reduction and internal fixation (ORIF, a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together so it can heal) on 8/27/2023. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 6/22/2020 with diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body and partial paralysis of one side of the body) following cerebral infarction (blood supply to the part of the brain was interrupted or reduced), and reduced mobility. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/19/2023 indicated Resident 1 had unclear speech, difficulty communicating some words or finishing thoughts, but was able, if prompted or given time. Resident 1 comprehends most conversations and had adequate hearing and vision. The MDS indicated Resident 1 needed one-person physical assistance with bed mobility, dressing, toilet use, personal hygiene, or bathing and required two or more persons physical assistance with transfer. The MDS further indicated Resident 1 was not steady during transfer between bed and chair or between bed and wheelchair, but able to stabilize with staff assistance. According to a review of the Quarterly Nursing Risks Evaluation / Assessments dated 7/19/2023, Resident 1 needed two or more persons with bed mobility and needed two-person physical assistance during transfers. A review of the osteoporosis (a bone disease where bones become weak and brittle) Care Plan revised on 8/3/2023 indicated Resident 1 was at risk for injuries, pathological fracture (occurs to areas of weakened bone caused by an underlying disease), and pain. The care plan goal indicated Resident 1 will remain free of injuries or complications related to osteoporosis through the review date. Further review of the care plan indicated there were no interventions included to prevent injury during transfer or to prevent accidents as a facility-wide priority. A review of the activities of daily living (ADLs, skills required to independently care for oneself such as eating, bathing and mobility) care plan initiated on 9/2/2022 and revised on 8/3/2023 indicated Resident 1 had a self-care deficit related to impaired balance and right-side weakness. The care plan goal indicated Resident 1 will maintain current level of function through the review date. The care plan interventions indicated Resident 1 required total assistance by two staff to move between surfaces (transferring from chair to bed). A review of the Situation Background Assessment or Appearance and Request (SBAR) dated 8/18/2023 at 1:30 p.m., indicated the situation was Resident 1 complained of right knee pain due to transfer from wheelchair back to bed after physical therapy. The SBAR indicated Licensed Vocational Nurse (LVN) 2 heard Resident 1 yelling out in pain and upon entering the room Resident 1 pointed to her right leg. LVN 2 attempted to readjust the right leg and Resident 1 cried out in pain. The SBAR indicated Resident 1 tried to explain how she hit her knee when CNA 1 transferred the resident from wheelchair back to bed after physical therapy. During assessment of Resident 1's right knee there was no signs of redness, warmth, or tenderness, but had a bump on the knee. The primary physician was notified and gave an order for x-ray of the right knee. The SBAR indicated Resident 1 was given Tylenol Extra Strength (medication for pain) 500 milligrams (mg., unit of measurement) two tablets for pain, with relief. According to a review of the Radiology Report (provides a translation of images into words) dated 8/18/2023, Resident 1 had an impacted fracture (break in the bones that occurred when one fragment of the bone is driven into a second piece of bone) of the distal femur (thigh bone just above the knee joint). A review of the Progress Notes dated 8/18/2023 indicated Resident 1's primary physician was notified of the Xray result and gave an order to transfer Resident 1 to GACH 1 for evaluation. A review of the Progress Notes dated 8/19/2023 at 1:14 a.m., indicated Resident 1 left the facility at 12:51 a.m. by ambulance. A review of the GACH 1 Emergency (ED) Provider Notes dated 8/19/2023 at 8:15 a.m. indicated Resident 1 was admitted to the GACH with severe pain in the right leg. The ED examination indicated Resident 1's right leg was swollen and externally rotated (when the thigh and the knee rotate outward, away from the body). A review of GACH 1's x-ray of Resident 1's right femur dated 8/19/2023 indicated a distal femoral fracture. A review of the admission Notes dated 8/20/2023 at 2:54 p.m., indicated the facility re-admitted Resident 1 from GACH 1 with diagnoses including closed fracture (bones push up against the skin but do not pierce the skin) of the right femur. The admission Notes indicated Resident 1 had a soft splint (material or device used to protect and immobilize a body part) on the right leg. Resident 1 did not have surgery. A review of the SBAR dated 8/22/2023 at 11:53 a.m., indicated the situation was Resident 1 had a right distal femur fracture and complained of unrelieved pain with current pain medication. The SBAR indicated the soft splint on Resident 1's right leg required re-evaluation and a more appropriate device with possible placement of hard cast. Pain management evaluated Resident 1 and gave an order for Norco (opioid medication for moderate to severe pain) every four hours. The SBAR indicated the primary physician was notified and gave order to transfer Resident 1 to GACH 2. A review of the GACH 2 Operative Note dated 8/27/2023 indicated Resident 1 had an open reduction and internal fixation (ORIF) of the supracondylar fracture (a break in the femur at the knee joint) of the right femur. A review of the admission Notes dated 8/29/2023 indicated the facility re-admitted Resident 1 from GACH 2. During an observation and concurrent interview on 8/30/2023 at 8:38 a.m., Resident 1 was lying in bed, with a cast and long brace on the right leg. Resident 1 stated she hurt herself during transfer from wheelchair to bed. Resident 1 pointed to her right knee indicating she had pain. During an interview on 8/30/2023 at 9:10 a.m., the MDS was reviewed with LVN 1, who stated and confirmed Resident 1 needed two or more persons for transfer to prevent injury to the resident. LVN 1 stated Resident 1 had a fracture after CNA 1 transferred Resident 1 by herself. During a concurrent interview and record review on 8/30/2023 at 12:52 p.m., Resident 1's ADL self-care deficit care plan revised on 8/3/2023 was reviewed with the director of nursing (DON). The DON stated Resident 1's care plan indicated the resident needed two persons for transfer. The DON stated Resident 1 may have hit her knee against the wheelchair when CNA 1 solely transferred Resident 1 from the wheelchair to the bed on 8/18/2023. The DON stated if two people were not assisting the resident, an accident may occur. The DON stated Resident 1, Had osteoporosis and a single snap or hitting of an object may trigger a fracture. During a telephone interview on 8/30/2023 at 5:30 p.m., certified nursing assistant (CNA 1) stated on 8/18/2023 at about 2 p.m., she solely transferred Resident 1 from wheelchair to bed. CNA 1 stated after transfer to bed, Resident 1 turned to her right side and complained of pain on the right leg. CNA 1 stated she could transfer Resident 1 by herself with no assistance. She is not a heavy patient. CNA 1 then stated LVN 2 provided Resident 1 with pain medication. A review of the facility policy titled, Safety and Supervision of Residents, revised on 1/2021, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The same policy indicated the Interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive device. Implementing interventions to reduce accident risks and hazards shall include ensuring that interventions were implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit one of two sampled (Resident 2) to remain in the facility and not transfer or discharge him unless the transfer / discharge was necessary and appropriate. The facility failed to: 1. Ensure the reason for discharging Resident 2 was because of one of the following: the resident's welfare and the resident's needs could not be met in the facility; his care needs could not be met at the facility, his health had improved and no longer needed the services provided by the facility, for the safety of individuals in the facility due to Resident 2's clinical or behavioral status, because of Resident 2's lack of payment, or because the facility ceased operation. 2. Ensure the attending physician (Physician 1) documented in Resident 2's clinical record the basis of the transfer / discharge. 3. Ensure Resident 2 was not transferred while an appeal hearing was pending. 4. Provide and document sufficient preparation and orientation to Resident 2 for a safe and orderly transfer or discharge from the facility. On 6/5/2023, the facility found out that Board and Care #2 (B&C, a lower level of care senior living facility licensed to care for residents who need some assistance with activities of daily living [ADLs, such as eating, walking, transfer, dressing, and bathing] but do not provide medical or nursing care), was accepting Resident 2 and proceeded to transfer him the following day, on 6/6/2023. As a result, Resident 2 developed untreated severe pain requiring B&C #2 staff to transfer Resident 2 to General Acute Care Hospital 1 (GACH 1) on 6/11/2023, five days after leaving the facility. Resident 2 was admitted to GACH 1, the same day, due to right lower leg wound infection and fever requiring intravenous (IV - through the vein) antibiotic (medication to fight bacterial infections) and IV Morphine (a narcotic medication [moderate doses dull the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions]. Cross Reference: F623, F624 Findings: A review of Resident 2's admission Record indicated the facility admitted the resident, a [AGE] year-old male, on 11/23/2022 with diagnoses including paraplegia (paralysis [inability to move] of the lower half of the body including both legs), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), polyneuropathy (a condition in which a person's peripheral nerves [outside the brain and spinal cord] are damaged; it affects the nerves in the skin, muscles, and organs), hypertension (abnormally elevated blood pressure), a right lower leg cellulitis (a bacterial [group of single-cell microorganisms] infection, bacteria enter the skin and tissue through a wound and the treatment includes antibiotics; without treatment it can be life-threatening), and unhealed left ischium (the lower part of the hip bone that supports a person while sitting, sometimes referred as the sit bone) pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones). A review of Resident 2's History and Physical exam dated 12/16/2022, indicated the resident had the capacity to understand and make decisions. A review of the Physician's Orders for Resident 2, dated 12/16/2022 and clarified on 4/11/2023, indicated to provide daily indwelling urinary catheter (a soft tubing inserted into the bladder draining urine into a bag outside the body) care; change the catheter and drainage bag if dislodge or malfunction; monitor for signs and symptoms of (urinary) infection every shift; monitor for pain; and irrigate with 30 to 60 milliliters (ml - unit of measure) as needed for heavy sediments (minerals in the urine) or blockage. A review of the Physician's Order for Resident 2, dated 12/22/2022, indicated the use of a low air loss mattress (LALM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) for wound management, check placement, functioning, and settings every shift. A review of the Physician's Order for Resident 2, dated 12/27/2022, indicated to monitor the resident for pain before and after wound treatment. A review of the Physician's Order for Resident 2, dated 1/19/2023, indicated to give gabapentin (medication used for nerve pain, which can be caused by different conditions after an injury) 300 milligrams (mg) one capsule by mouth four times a day for neuropathic pain (happens when the nervous system is damaged or not working correctly). A review of the Physician's Order for Resident 2, dated 3/2/2023, indicated to give nortriptyline (medication used for nerve pain) 25 mg by mouth every night. A review of the form Notice of Transfer / Discharge to Resident 2 with notification date of 5/3/2023, indicated the resident was self-responsible and the effective date of discharge was 6/6/2023 to B&C #2 (this date and the specific B&C were not known on 5/3/2023). The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice also indicated that per the resident's request, as another reason for discharge which was handwritten on the notice. A review of the form Notice of Proposed Transfer and Discharge to Resident 2 dated and signed by a facility representative on 5/10/2023 and hand-delivered to the resident, who did not sign the form, indicated a discharge effective date of 6/9/2023 to B&C #1. The reasons for discharge were: - The discharge is necessary for your welfare and your need cannot be met in the facility. - The safety of individual in the facility is endangered by your presence. - The health of individuals in the facility is endangered by your presence. A review of the Physician's Progress Notes for Resident 2 before or on 5/3/2023 and 5/10/2023 (dates of the transfer / discharge notices) indicated no documentation justifying the need to transfer / discharge Resident 2. A review of Resident 2's Progress Notes, dated 5/24/2023, by the Interdisciplinary team (IDT, group of healthcare professionals from different disciplines who participate in the care of the resident), indicated a 30-day Notice follow-up which was initially due to violation of the facility's policy on no illicit drugs or alcohol use. The note indicated Suddenly requested a copy of the 30-day notice issued originally which he crumbled and threw away, provided with the original notice as requested. Resident 2 stated he contacted a Center to assist him with placement and was told the facility would assist him with a safe placement. A review of Resident 2's Progress Notes, dated 5/25/2023, indicated the Social Services Director (SSD) coordinated with Social Services Assistant (SSA) to assist Resident 2 looking for an Assisted Living Facility (ALF). A review of the Physician's Order for Resident 2, dated 5/25/2023, indicated to provide daily treatment to the right lower leg cellulitis, cleansing with normal saline (it is a mixture of salt and water), apply hydrogel dressing (a special dressing that absorbs wound discharge), and cover with a foam dressing. A review of Resident 2's most recent Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool) was dated 5/28/2023. The MDS indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 2 did not have mood or behavior problems. Resident 2 was unable to walk and needed extensive assistance with one-person physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident 2 could move around using a wheelchair (locomotion) with supervision. The MDS Section for Discharge Plan indicated there was no active discharge planning for the resident to return to the community. For the MDS question Do you want to talk to someone about possibility of leaving this facility and returning to live and receive services in the community? Resident 2's response was documented as No. A review of the Physician's Progress Notes for Resident 2 dated 5/31/2023 by the resident's attending physician, indicated the resident was seen and explained the plan was to discharge him to another SNF or a lower level of care facility that accepted wound treatment. The Progress Note indicated Resident 2 should not be located near a liquor store due to alcohol abuse. Transfer the resident to a safe facility where illicit drugs transactions are not occurring or available due to the resident having illegal drugs. This is for safety of this resident and other surrounding residents. Physician 1 did not document why the needs of Resident 2 could not met at the facility. A review of Resident 2's Plan of Care for the months of 4/2023, 5/2023, and 6/2023, indicated no active plan to discharge the resident to another Skilled Nursing Facility (SNF) or to a lower level of care setting and no care plan addressing Resident 2's behavior of using drugs or alcohol. A review of Resident 2's Progress Notes dated 6/5/2023 and timed at 4:16 p.m., the SSA documented she provided the resident with another location: B&C #2, for possible discharge the same day (6/5/2023) and Resident 2 expressed he would like to be discharged as soon as possible. The SSA did not indicate checking B&C #2 was not close to a liquor store or to an area where illegal drugs were sold as Resident 2's attending physician had recommended on 5/31/2023, for Resident 2's safety. A review of the Physician's Order for Resident 2, dated 6/5/2023 and timed at 4:37 p.m., indicated to discharge the resident to B&C #2 with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of the Physician's Progress Notes for Resident 2 did not include the physician had evaluated Resident 2 as eligible to receive hospice care (which include terminal illness and life expectancy less than six month) and that the physician had explained to Resident 2 the benefits of hospice care or that the resident understood and consented to receive hospice care. A review of the Physician's Order for Resident 2, dated 6/6/2023, timed at 10:04 a.m., indicated the resident would be discharged to B&C #2 on 6/6/2023 at 12:30 p.m. A review of Resident 2's undated Discharge Summary, signed by an IDT staff and not signed by Resident 2's attending physician, indicated the resident's stay in the facility was from 11/23/2022 to 6/6/2023. In the section for Recapitulation of the Resident's Stay, it was documented the resident was admitted for rehabilitation, antibiotic therapy, and pain, wound, medication management. In the section for Transfer / Discharge was Necessary Due To, it was indicated the discharge was per resident's request. A review of GACH 1's Nursing Narrative Note for Resident 2, dated 6/11/2023, indicated Resident 2 was received from B&C #2 facility due to right lower leg wound infection and fever. Resident 2 required an IV antibiotic to treat the infection and IV Morphine for pain. A review of the document from the Department of Health Care Services Office of Administrative Hearings and Appeal indicated that on 5/24/2023, the Office of Administrative Hearings and Appeal received a request for hearing from Resident 2 concerning the facility's determination to involuntarily transfer or discharge the resident. The hearing was scheduled to be conducted as a teleconference on 6/8/2023 at 1 p.m. The document indicated under Notice of Rights that the facility may not involuntarily transfer or discharge the resident while this appeal is pending unless the failure to transfer or discharge would endanger the health or safety of the resident or other individuals in the facility. On 6/12/2023, at 2:29 p.m., during a telephone interview with Resident 2, who was still at GACH 1, he stated, The facility discharged me as quick as possible from over there. Resident 2 stated he did not request to be discharged from the facility and had a pending appeal hearing. On 6/13/2023, at 11:25 a.m., during an interview, LVN 1 stated Resident 2 showed LVN 1 the Transfer / Discharge Notice (LVN did not remember the date) because Resident 2 did not understand it. LVN 1 explained the form to Resident 2 and that he (Resident 2) had 10 days to appeal. LVN 1 stated Resident 2 told him (no date specified) he had appealed but did not know the date of the hearing. On 6/13/2023, at 11:54 a.m., during an interview, the SSA stated Resident 2 received the 30-day Notice of Transfer / discharge on [DATE] and the resident refused to sign it. SSA stated she helped Resident 2 looking for places to move in all areas and she started sending out referrals (to other facilities) on 6/1/2023. On 6/14/2023 at 10:59 a.m., during an interview, the SSA stated it was the facility's duty to ensure Resident 2 was discharged somewhere safe and appropriate and she did this by relying on the word of the placement agency. On 6/14/2023 at 12:24 p.m., during an interview, Quality Assurance (QA) nurse stated Resident 2's Notice of Transfer / Discharge was dated 5/3/2023, when the resident requested to go to an ALF and the Notice was completed on 6/6/2023. This form was given Resident 2 on 6/6/2023, the day he was discharged . The original is with the patient and the copies stay with the facility. The QA stated she did not tell Resident 2 had the right to stay in the facility while the discharge was pending because I did not know about the appeal. I only know about the 30-day Notice because it was told to us in the Stand-Up meeting. On 6/14/2023 at 12:59 p.m., during an interview, the SSD stated the protocol for transfer / discharge of residents was First, we see to it that the patient is ok. We notify the doctor to get the discharge order. Then we start looking for a place for the patient. If he is accepted, we let the resident know about it and if the resident accepts that location, we get the final discharge order. The SSD also stated she was aware Resident 2 had a discharge appeal hearing but she did not know the date. On 6/14/2023 at 2:20 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 was provided a 30-day notice on 5/10/2023. When asked about Resident 2's transfer / discharge appeal hearing, the DON stated the Administrator receives the appeal hearing notices. The DON stated, I know he had an appeal date, but he was discharged so the appeal did not take place. We contacted the appeals department to let them know Resident 2 was discharged and where he discharged to. The DON stated Resident 2 was discharged pending an appeal because he requested to be discharged . On 6/14/2023 at 2:58 p.m., during a telephone interview, the Administrator stated Resident 2 was discharged despite having the appeal hearing pending because he did not want to fight the discharge. Resident 2 said he appealed so that he could buy time. The Administrator said Resident 2 went to a couple of places and he finally found a place that he fell in love with and he wanted to go immediately the next day. On 6/28/2023, at 12:19 p.m., during a telephone interview, Physician 1 stated Resident 2 needed to be in a facility where the resident did not have a liquor store and drug dealing nearby and where he could receive wound care. On 6/30/2023, at 11:37 a.m., during a telephone interview, Ombudsman 1 stated the office did not get notification from the facility of a facility-initiated discharge transfer. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge with the reasons for the discharge, the effective date of the discharge and the location to which the resident was discharged . A copy of the Notice is sent to the Office of the State Long-Term Care Ombudsman. A review of the facility's P&P titled, Discharging the Resident, reviewed 1/2022, indicated the facility will educate the resident on who will be providing the resident's care after discharge. It also indicated facility-initiated discharges will include on the assessment consideration of discharge timeframes - in terms of what was safest and in the best interest of the patient - evaluating medical necessity, family and patient preference and desires, appropriateness of the discharge, resources available at the time of discharge, and ultimately the order of the physician. The policy indicated discharges can be frightening to the resident and to approach the discharge in a positive manner. A review of the facility's policy and procedure titled, Transfer or Discharge, Preparing a Resident for, revised 12/2016, indicated residents will be prepared in advance for discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from the complaint investigation dated 6/13/23. Based on interview and record review, for one of two sampled residents (Resident 2) the facility failed to ensure: 1. Resident 2 was notified at least 30 days before the resident was transferred or discharged and the reasons for the move in writing and in a manner the resident understands. 2. The notice included the effective date of the discharge and the location to which the resident was discharged . 3. A copy of the facility-initiated notice was sent to a representative of the Office of the State Long-Term Care Ombudsman (residents' advocate group). On 5/3/2023, the facility issued a Notice of Discharge to Resident 2 without an effective date and a location since it was not until 6/5/2023 at 4:16 p.m. that the facility found out Board and Care #2 (B&C, a lower level of care senior living facility licensed to care for residents who need some assistance with activities of daily living [ADLs, such as eating, walking, transfer, dressing, and bathing] but do not provide medical or nursing care) was accepting Resident 2's admission. The facility proceeded to transfer Resident 2 the following day (6/6/2023) at noon, in less than 24 hours without ensuring B&C #2 could meet Resident 2's care needs, and without affording enough time for Resident 2 to make an informed decision to consent to the transfer and without allowing the Ombudsman Program to assist Resident 2 with his discharge / transfer rights. As a result, Resident 2 was discharged hurriedly and on 6/11/2023, five days after discharge from the facility, Resident 2's condition deteriorated and B&C #2 staff sent the Resident 2 to General Acute Care Hospital 1 (GACH 1), where he was admitted due to right lower leg wound infection and fever requiring intravenous (IV - through the vein) antibiotic (medication to fight bacterial infections) and IV Morphine (a narcotic medication [moderate doses dull the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions]. Cross Reference: F622, 624 Findings: A review of Resident 2's admission Record indicated the facility admitted the resident, a [AGE] year-old male, on 11/23/2022 with diagnoses including paraplegia (paralysis [inability to move] of the lower half of the body including both legs), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), polyneuropathy (a condition in which a person's peripheral nerves [outside the brain and spinal cord] are damaged; it affects the nerves in the skin, muscles, and organs), hypertension (abnormally elevated blood pressure), a right lower leg cellulitis (a bacterial [group of single-cell microorganisms] infection, bacteria enter the skin and tissue through a wound and the treatment includes antibiotics; without treatment it can be life-threatening), and unhealed left ischium (the lower part of the hip bone that supports a person while sitting, sometimes referred as the sit bone) pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones). A review of Resident 2's History and Physical exam dated 12/16/2022, indicated the resident had the capacity to understand and make decisions. A review of the Physician's Order for Resident 2, dated 12/27/2022, indicated to monitor the resident for pain before and after wound treatment. A review of the form Notice of Transfer / Discharge to Resident 2, with a notification date of 5/3/2023, indicated Resident 2 was self-responsible and the effective date of discharge was 6/6/2023 to B&C #2 (the specific B&C were not known on 5/3/2023). The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. A handwritten note as another reason for discharge was per resident's request. A review of the form Notice of Proposed Transfer and Discharge to Resident 2 dated and signed by a facility representative on 5/10/2023 and hand-delivered to the resident, who did not sign the form, indicated a discharge effective date of 6/9/2023 to B&C #1. The reasons for discharge were: - The discharge is necessary for your welfare and your need cannot be met in the facility. - The safety of individual in the facility is endangered by your presence. - The health of individuals in the facility is endangered by your presence. A review of Resident 2's Progress Notes, dated 5/24/2023, by the Interdisciplinary team (IDT, group of healthcare professionals from different disciplines who participate in the care of the resident), indicated, A 30-day Notice follow-up which was initially due to violation, of the facility's policy on no illicit drugs or alcohol use. The note indicated, Suddenly requested a copy of the 30-day notice issued originally, which he crumbled and threw away, was provided with the original notice as requested. The Progress Note indicated Resident 2 stated he contacted a Center to assist him with placement and was told the facility would assist him with a safe placement. A review of Resident 2's Progress Notes, dated 5/25/2023, indicated the Social Services Director (SSD) coordinated with Social Services Assistant (SSA) to assist Resident 2 looking for an Assisted Living Facility (ALF). A review of Resident 2's most recent Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool) was dated 5/28/2023. The MDS indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 2 did not have mood or behavior problems. Resident 2 was unable to walk and needed extensive assistance with one-person physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident 2 could move around using a wheelchair (locomotion) with supervision. The MDS Section for Discharge Plan indicated there was no active discharge planning for the resident to return to the community. For the MDS question Do you want to talk to someone about possibility of leaving this facility and returning to live and receive services in the community? Resident 2's response was documented as No. A review of the Physician's Progress Notes for Resident 2 dated 5/31/2023 by the resident's attending physician, indicated the resident was seen and discussed the plan was to discharge him to another facility or a lower level of care facility that accepted wound treatment. Resident 2 should not be located near a liquor store due to alcohol abuse. Transfer the resident to a safe facility where illicit drugs transactions are not occurring or available due to the resident having illegal drugs. This is for safety of this resident and other surrounding residents. A review of Resident 2's Plan of Care for the months of 4/2023, 5/2023, and 6/2023, indicated no active plan to discharge the resident to another Skilled Nursing Facility (SNF) or to a lower level of care setting and there was no care plan addressing Resident 2's behavior of using drugs or alcohol. A review of Resident 2's Progress Notes dated 6/1/2023, the SSA documented she had faxed transfer referrals to three SNF and one assisted living facility (ALF). According to a review of Resident 2's Progress Notes dated 6/1/2023, documented by the SSA, the SSA and Resident 2 went to ALF #1 but were told they could not accept him because of the wounds. A review of Resident 2's Progress Notes dated 6/5/2023 and timed at 4:16 p.m., the SSA documented she provided the resident with another location: B&C #2, for possible discharge the same day (6/5/2023) and Resident 2 expressed he would like to be discharged as soon as possible. The SSA did not indicate checking that B&C #2 was not close to a liquor store or to an area where illegal drugs were sold as Resident 2's attending physician had recommended on 5/31/2023, for Resident 2's safety. A review of the Physician's Order for Resident 2, dated 6/5/2023 and timed at 4:37 p.m., indicated to discharge the resident to B&C #2 with medications and on hospice care. A review of Resident 2's Progress Notes for 6/5/2023 and 6/6/2023 did not include documentation Resident 2 was explained and understood the services provided by the B&C. The documentation did not indicate B&C #2 was informed about Resident 2's alcohol and illegal drug use. A review of the Physician's Order for Resident 2, dated 6/6/2023, timed at 10:04 a.m., indicated the resident would be discharged to B&C #2 on 6/6/2023 at 12:30 p.m. with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of GACH 1's Nursing Narrative Note for Resident 2, dated 6/11/2023, indicated Resident 2 was received from B&C #2 facility due to right lower leg wound infection and fever. Resident 2 was admitted to GACH 1 because he required an IV antibiotic to treat the infection and IV Morphine for pain. On 6/12/2023, at 2:29 p.m., during a telephone interview with Resident 2, who remained at GACH 1, he stated, The facility discharged me as quick as possible from over there. Resident 2 stated he did not request to be discharged from the facility. On 6/13/2023, at 11:25 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated Resident 2 showed LVN 1 the Transfer / Discharge Notice (LVN did not remember the date) because Resident 2 did not understand it. LVN 1 explained the form to Resident 2 and that he (Resident 2) had 10 days to appeal. LVN 1 stated Resident 2 told him (no date specified) he had appealed but did not know the date of the hearing. On 6/13/2023, at 11:54 a.m., during and interview, the SSA stated Resident 2 received the 30-day Notice of Transfer / discharge on [DATE] and the resident refused to sign it. The SSA stated she helped Resident 2 look for places to move in all areas and she started sending out referrals (to other facilities) on 6/1/2023. On 6/14/2023 at 12:24 p.m., during an interview, the Quality Assurance (QA) nurse stated Resident 2's Notice of Transfer / Discharge was dated 5/3/2023, when the resident requested to go to an ALF and the Notice was completed on 6/6/2023. This form was given to Resident 2 on 6/6/2023, the day he was discharged . The original was with the patient and the copies stay with the facility. The QA stated she did not tell Resident 2 he had the right to stay in the facility while the discharge was pending because, I did not know about the appeal. I only know about the 30-day Notice because it was told to us in the Stand-Up meeting. On 6/14/2023 at 12:59 p.m., during an interview, the SSD stated the protocol for transfer / discharge of residents was, First, we see to it that the patient is ok. We notify the doctor to get the discharge order. Then we start looking for a place for the patient. If he is accepted, we let the resident know about it and if the resident accepts that location, we get the final discharge order. The SSD also stated she was aware Resident 2 had a discharge appeal hearing but she did not know the date. On 6/14/2023 at 2:20 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 was provided a 30-day notice on 5/10/2023. On 6/14/2023 at 2:58 p.m., during a telephone interview, the Administrator stated Resident 2 went to a couple of places and he finally found a place that he fell in love with and he wanted to go immediately the next day. On 6/28/2023, at 12:19 p.m., during a telephone interview, Resident 2's attending physician (Physician 1) stated Resident 2 needed to be in a facility where the resident did not have a liquor store and drug dealing nearby and where he could receive wound care. On 6/30/2023, at 11:37 a.m., during a telephone interview, Ombudsman 1 stated the office did not get notification from the facility of Resident 2's facility-initiated transfer / discharge. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge with the reasons for the discharge, the effective date of the discharge and the location to which the resident was discharged . A copy of the Notice is sent to the Office of the State Long-Term Care Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient preparation to ensure a safe discharge for one of two sampled residents (Resident 2), who had an unhealed left ischium (the lower part of the hip bone that supports a person while sitting, sometimes referred as the sit bone) pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones) and had a right lower leg cellulitis (a bacterial [group of single-cell microorganisms] infection, bacteria enter the skin and tissue through a wound and the treatment includes antibiotics; without treatment it can be life-threatening). On 6/6/2023, the facility discharged Resident 2 to a lower level of care, a Board and Care facility (B&C, a senior living facility licensed to care for residents who need some assistance with activities of daily living [ADLs, such as eating, walking, transfer, dressing, and bathing], but do not provide medical or nursing care), where Resident 2's medical and nursing needs could not be met. As a result, Resident 2 developed untreated severe pain requiring the B&C staff to transfer Resident 2 to General Acute Care Hospital 1 (GACH 1) on 6/11/2023, five days after leaving the facility. Resident 2 was admitted to GACH 1, the same day, due to right lower leg wound infection and fever requiring intravenous (IV - through the vein) antibiotic (medication to fight bacterial infections) and IV Morphine (a narcotic medication [moderate doses dull the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions]. Cross Reference: F622, F623 Findings: A review of Resident 2's admission Record indicated the facility admitted the resident, a [AGE] year-old male, on 11/23/2022 with diagnoses including paraplegia (paralysis [inability to move] of the lower half of the body including both legs), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), polyneuropathy (a condition in which a person's peripheral nerves [outside the brain and spinal cord] are damaged; it affects the nerves in the skin, muscles, and organs), hypertension (abnormally elevated blood pressure), right lower leg cellulitis, and Stage IV pressure ulcer to the left ischium. Resident 2 was responsible for himself. A review of Resident 2's History and Physical exam dated 12/16/2022, indicated the resident had the capacity to understand and make decisions. A review of the Physician's Orders for Resident 2, dated 12/16/2022 and clarified on 4/11/2023, indicated to provide daily indwelling urinary catheter (a soft tubing inserted into the bladder draining urine into a bag outside the body) care; change the catheter and drainage bag if dislodge or malfunction; monitor for signs and symptoms of (urinary) infection every shift; monitor for pain; and irrigate with 30 to 60 milliliters (ml - unit of measure) as needed for heavy sediments (minerals in the urine) or blockage. A review of the Physician's Order for Resident 2, dated 12/22/2022, indicated the use of a low air loss mattress (LALM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) for wound management, check placement, functioning, and settings every shift. A review of the Physician's Order for Resident 2, dated 12/27/2022, indicated to monitor the resident for pain before and after wound treatment. A review of the Physician's Order for Resident 2, dated 1/19/2023, indicated to give gabapentin (medication used for nerve pain, which can be caused by different conditions after an injury) 300 milligrams (mg) one capsule by mouth four times a day for neuropathic pain (happens when the nervous system is damaged or not working correctly). A review of the Physician's Order for Resident 2, dated 3/2/2023, indicated to give nortriptyline (medication used for nerve pain) 25 mg by mouth every night. A review of the form Notice of Transfer / Discharge to Resident 2 with notification date of 5/3/2023, indicated the resident was self-responsible and the effective date of discharge was 6/6/2023 to B&C #2 (this date and the specific B&C were not known on 5/3/2023). The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. A handwritten note as another reason for discharge was per resident's request. A review of the form Notice of Proposed Transfer and Discharge to Resident 2 dated and signed by a facility representative on 5/10/2023 and hand-delivered to the resident, who did not sign the form, indicated a discharge effective date of 6/9/2023 to B&C #1. The reasons for discharge were: - The discharge is necessary for your welfare and your need cannot be met in the facility. - The safety of individual in the facility is endangered by your presence. - The health of individuals in the facility is endangered by your presence. A review of Resident 2's Progress Notes, dated 5/24/2023, by the Interdisciplinary team (IDT, group of healthcare professionals from different disciplines who participate in the care of the resident), indicated a 30-day Notice follow-up which was initially due to violation of the facility's policy on no illicit drugs or alcohol use. The note indicated Suddenly requested a copy of the 30-day notice issued originally which he crumbled and threw away, provided with the original notice as requested. Resident 2 stated he contacted a Center to assist him with placement and was told the facility would assist him with a safe placement. A review of Resident 2's Progress Notes, dated 5/25/2023, indicated the Social Services Director (SSD) coordinated with Social Services Assistant (SSA) to assist Resident 2 looking for an Assisted Living Facility (ALF). A review of the Physician's Order for Resident 2, dated 5/25/2023, indicated to provide daily treatment to the right lower leg cellulitis, cleansing with normal saline (it is a mixture of salt and water), apply hydrogel dressing (a special dressing that absorbs wound discharge), and cover with a foam dressing. A review of Resident 2's most recent Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool) was dated 5/28/2023. The MDS indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 2 did not have mood or behavior problems. Resident 2 was unable to walk and needed extensive assistance with one-person physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident 2 could move around using a wheelchair (locomotion) with supervision. The MDS Section for Discharge Plan indicated there was no active discharge planning for the resident to return to the community. For the MDS question Do you want to talk to someone about possibility of leaving this facility and returning to live and receive services in the community? Resident 2's response was documented as No. A review of the Physician's Progress Notes for Resident 2 dated 5/31/2023 by the resident's attending physician, indicated the resident was seen and explained the plan was to discharge him to another SNF or a lower level of care facility that accepted wound treatment. Resident 2 should not be located near a liquor store due to alcohol abuse. Transfer the resident to a safe facility where illicit drugs transactions are not occurring or available due to the resident having illegal drugs. This is for safety of this resident and other surrounding residents. A review of Resident 2's Plan of Care for the months of 4/2023, 5/2023, and 6/2023, indicated no active plan to discharge the resident to another Skilled Nursing Facility (SNF) or to a lower level of care setting and no care plan addressing Resident 2's behavior of using drugs or alcohol. A review of Resident 2's Progress Notes dated 6/1/2023, the SSA documented she had faxed transfer referrals to three SNF and one assisted living facility (ALF). According to a review of Resident 2's Progress Notes dated 6/1/2023, documented by the SSA, indicated SSA and Resident 2 went to ALF #1 but were told they could not accept him because of the wounds. A review of Resident 2's Progress Notes dated 6/5/2023 and timed at 4:16 p.m., the SSA documented she provided the resident with another location: B&C #2, for possible discharge the same day (6/5/2023) and Resident 2 expressed he would like to be discharged as soon as possible. The SSA did not indicate checking B&C #2 was not close to a liquor store or to an area where illegal drugs were sold as Resident 2's attending physician had recommended on 5/31/2023, for Resident 2's safety. A review of the Physician's Order for Resident 2, dated 6/5/2023 and timed at 4:37 p.m., indicated to discharge the resident to B&C #2 with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of the Physician's Progress Notes for Resident 2 did not include the physician had evaluated Resident 2 as eligible to receive hospice care (which include terminal illness and life expectancy less than six month) and that the physician had explained to Resident 2 the benefits of hospice care or that the resident understood and consented to receive hospice care. A review of Resident 2's Progress Notes for 6/5/2023 and 6/6/2023 did not include documentation by social services, nursing, or the IDT about the reason for hospice, eligibility, Resident 2's understanding of hospice care and his consent. There was no documentation the SSD or the SSA had contacted a hospice agency, provided a referral, gave information regarding Resident 2's care needs including pain management, urinary catheter care, and frequency of wound care. There was no documentation Resident 2 was explained and understood the services provided by the B&C. The documentation did not indicate B&C #2 was informed about Resident 2's alcohol and illegal drug use. A review of the Physician's Order for Resident 2, dated 6/6/2023, timed at 10:04 a.m., indicated the resident would be discharged to B&C #2 on 6/6/2023 at 12:30 p.m. with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of Resident 2's undated Discharge Summary, signed by an IDT staff and not signed by Resident 2's attending physician, indicated the resident's stay in the facility was from 11/23/2022 to 6/6/2023. In the section for Recapitulation of the Resident's Stay, it was documented the resident was admitted for rehabilitation, antibiotic therapy, and pain, wound, medication management. In the section for Transfer / Discharge was Necessary Due To, it was indicated the discharge was per resident's request. A review of Resident 2's Post Discharge Plan of Care, undated, indicated the resident's discharge date was 6/6/2023. Resident 2's specific care needs, safety precautions, wound treatment instructions, including the indwelling catheter care, and the needed assistance with ADLs were not included. The name of the hospice agency, contact staff, and contact number were not included. A review of GACH 1's Nursing Narrative Note for Resident 2, dated 6/11/2023, indicated Resident 2 was received from B&C #2 facility due to right lower leg wound infection and fever. Resident 2 required an IV antibiotic to treat the infection and IV Morphine for pain. A review of GACH 1's Emergency Department (ED) Physician's Note for Resident 2, dated 6/11/2023, indicated Resident 2 complained of redness and swelling to his right lower leg with drainage coming from it over the last day. Resident 2's symptoms started four days prior, he had a fever of 100.1degrees Fahrenheit (°F, normal body temperature range 97°F - 99 °F) and pain rated eight (8/10, in a pain scale from zero indicating no pain and 10 the most excruciating pain possible). Resident 2 would be admitted to the hospital for IV antibiotics. On 6/12/2023, at 2:29 p.m., during a telephone interview with Resident 2, who was still at GACH 1, he stated, The facility discharged me as quick as possible from over there. Resident 2 stated he did not receive any hospice services at B&C #2 and did not receive wound care until after four days he was at B&C #2. Resident 2 stated that in the past his wound had become infected when the dressings were not changed daily. On 6/13/2023, at 11:03 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 2 was discharged to B&C #2 with Hospice Agency 1 (HA 1) and a three-week supply of medications. LVN 2 stated Resident 2 would not have been able to perform his own wound care and that the resident's hospice care should have been in place prior to his discharge. During an interview, on 6/13/2023, at 11:54 a.m., the SSA stated she used an outside placement agency to find a facility and set up hospice care, home health agency (HHA) care, or a wound care for Resident 2. The SSA stated she did not verify what agencies (Hospice or HHA) would provide care to Resident 2 or what type of services the resident qualified for. The SSA also stated she did not know if the caregivers at B&C #2 could perform wound care. On 6/13/2023, at 12:25 p.m., during a call to HA 1, staff stated Resident 2 was not a current patient and had not been their patient in the recent months. On 6/13/2023, at 12:58 p.m., during an interview, the Quality Assurance Nurse (QA 1) stated Resident 2 was discharged with HA 1 and it was the job of the social services staff to contact HA 1 and make sure wound and other care Resident 2 needed were in place to ensure a safe and appropriate discharge. QA 1 stated part of Resident 2's post discharge plan of care included ensuring wound care and other services were in place prior to Resident 2 leaving the facility. During an interview, on 6/14/2023 at 10:59 a.m., the SSA stated it was the facility's duty to ensure Resident 2 was discharged somewhere safe and appropriate and she did this by relying on the word of the placement agency. On 6/14/2023 at 11:43 a.m., during a telephone interview, Wound Care Company A (WCC A) Case Manager 1 (CM 1) stated their staff visited Resident 2 at B&C #2 to provide services (wound care) only once on 6/9/2023 (3 days after his discharge from the facility and two days prior to being hospitalized ). During an interview on 6/14/2023 at 12:59 p.m., the SSD stated Resident 2 required wound care and the facility was to make sure wound care, HHA or hospice was in place before transferring Resident 2. On 6/14/2023 at 2:20 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 was provided a 30-day notice on 5/10/2023, and wound care services should have been in place prior to discharge and social services staff was to verify they were in place. The DON stated, It was our responsibility to make sure that it was done. If Resident 2 was discharged and the required services were not provided, then it was not a safe or appropriate discharge. On 6/28/2023, at 12:19 p.m., during a telephone interview, Resident 2's attending physician (Physician 1) stated Resident 2 did not qualify for hospice (did not have a terminal illness and was not near death and needing end-of-life care) but the facility's staff (did not name the staff member) told him they could only discharge Resident 2 if he needed to include hospice care. Physician 1 confirmed what he wrote in his progress notes on 5/31/2023, that Resident 2 needed to be in a facility where the resident did not have a liquor store and drug dealing nearby and where he could receive wound care. On 6/28/2023, at 4:13 p.m., during a telephone interview, Placement Agent 1 (PA 1) stated she was a marketer for different facility types and worked alone. PA 1 stated she knew the Administrator and the DON for a long time and was assisting placing Resident 2. On 6/30/2023, at 11:37 a.m., during a telephone interview, Ombudsman 1 stated the office did not get notification from the facility of a facility-initiated discharge transfer. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. A review of the facility's P&P titled, Discharging the Resident, reviewed 1/2022, indicated the facility will educate the resident on who will be providing the resident's care after discharge. It also indicated facility-initiated discharges will include on the assessment consideration of discharge timeframes - in terms of what was safest and in the best interest of the patient - evaluating medical necessity, family and patient preference and desires, appropriateness of the discharge, resources available at the time of discharge, and ultimately the order of the physician. The policy indicated that discharges can be frightening to the resident and to approach the discharge in a positive manner. A review of the facility's P&P titled, Discharge Summary and Plan, revised 12/2016, indicated every resident would be evaluated for his discharge needs and will have an individualized post discharge plan. The discharge plan will include arrangements that have been made for follow-up care and services. A review of the facility's policy and procedure titled, Transfer or Discharge, Preparing a Resident for, revised 12/2016, indicated residents will be prepared in advance for discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing- related problems) was provided the necessary respiratory care and services consistent with professional standards of practice. The facility failed to: 1. Ensure Resident 1 was given 100% oxygen by non- rebreather mask (face mask that delivers high concentration of oxygen) while waiting for the paramedics to arrive. Resident 1 was placed on Bilevel Positive Airway Pressure (BiPAP, machine that helps with breathing and delivers pressurized air through a face mask for those that have spontaneous breathing) mask with no oxygen supply. Resident 1's oxygen saturation continued to drop, and patient became unresponsive to painful stimuli (a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli such as shaking of the shoulders). 2. Implement the person-centered care plan interventions to monitor and document changes in Resident 1's orientation, increased restlessness, and air hunger, monitor and document or report breathing abnormalities. These deficient practices resulted in delay in providing necessary lifesaving intervention before the paramedics arrived. Resident 1's oxygen saturation (amount of oxygen circulating in the blood) dropped to 76% (ideal range is 95% to 100%) and patient was transferred to the general acute hospital (GACH 2) where Resident 1 was admitted to the intensive care unit (ICU, department of the hospital with patients who are dangerously ill and are kept under constant observation) and stayed for six days. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 10/2/2019 and readmitted on [DATE] with diagnoses including respiratory failure (airways cannot adequately provide oxygen to the body), chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing -related problems) and sleep apnea (condition in which breathing stops and restarts many times while sleeping). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/30/2023 indicated Resident 1 was alert to year and month only. Resident 1 needed one-person physical assistance with dressing, eating, toilet use, personal hygiene and two or more persons physical assistance with bed mobility and bathing. The MDS indicated Resident 1 had shortness of breath or trouble breathing when sitting at rest and was on oxygen therapy. A review of the Care Plan initiated on 2/1/2023 indicated Resident 1 had shortness of breath related to decreased energy and fatigue, hypoxia (low levels of oxygen in the body), COPD exacerbation (worsening of the COPD) and oxygen desaturation (decrease in oxygen level in the blood). The goal indicated Resident 1 would have no complications related to shortness of breath. The care plan interventions included to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger, monitor and document or report breathing abnormalities to the physician including bradypnea (slow breathing less than 12 breaths per minute [bpm]), tachypnea (increased breathing, normal range 12 to 20 bpm) and to give 15 liters of oxygen per minute (LPM, flow rate of oxygen) by non-rebreather mask. A review of the Care Plan dated 2/10/2023 indicated Resident 1 had impaired breathing function and dependent on oxygen. The care plan goal indicated Resident 1 will recover oxygen saturation level more than 95% within five minutes and will keep oxygen level above 95% all the time. The care plan interventions indicated to give oxygen up to maximum level until oxygen saturation had recovered and set BIPAP under the care of the respiratory therapist (RT, trained health professionals who help treat and restore function for patients with airway or breathing problems). A review of the Physician's Order Summary Report dated 2/10/2023 indicated Resident 1 to receive oxygen at two liters by nasal cannula (nasal prongs) continuously for respiratory failure, monitor oxygen saturation every six hours and BiPAP at bedtime for hypoventilation (breathing too shallow or too slow). During review of the GACH 1 Physician Discharge summary dated [DATE], Resident 1 was initially admitted (2/6/23) at GACH 1 as code stroke (suspected stroke) but ruled out. The Summary indicated Resident 1 had respiratory failure, obesity hypoventilation syndrome COPD and oxygen dependence. A review of the Situation, Background, Assessment and Request (SBAR) Communication and Progress Note dated 2/10/2023 indicated Resident 1 was re-admitted from GACH 1 at 4:40 PM. The SBAR indicated at 6:12 PM, Resident 1's vital signs (clinical measurements specifically the heart rate, temperature, breathing rate and blood pressure (BP) that indicate the state of body functions) were BP of 148/66 (normal 120/80), heart rate of 68 bpm (normal range 60 to 100 bpm), breathing at 18 bpm (normal 12 to 20), temperature of 97.2 Fahrenheit (F, range from 97 F to 99 degrees F) and oxygen saturation of 98% on oxygen by nasal cannula at four liters of oxygen. A review of the Paramedics Patient Care Report dated 2/10/2023 at 9:59 PM indicated on arrival to facility, Resident 1 was in bed and on BiPAP machine with no supplemental oxygen. The Patient Care Report indicated Resident 1's family member came for a visit and found Resident 1 unresponsive with a low oxygen saturation and it was unknown for how long. The Paramedic Patient Care Report (Notes) indicated Resident 1 had oxygen saturation of 76%, was placed on 15 liters of oxygen by non-rebreather mask and started breathing on her own. The oxygen saturation improved to 100%. Resident 1's Glasgow Coma Scale (GCS, determines the level of consciousness) was three (indicated no response to pain). Resident 1 was taken to GACH 2. A review of the Progress Notes dated 2/10/23 at 10:24 p.m. notes indicated Resident 1 remained on oxygen at four liters by nasal cannula and was on continuous monitoring for oxygen saturation while waiting for the Respiratory Therapist (RT) to set up the BIPAP. At 9:30 PM, the notes indicated Resident 1 had decreasing saturation level and continued with oxygen treatment. The nursing documentation did not specify how much oxygen was given nor the oxygen saturation. At 9:50 p.m. Resident 1 had .abrupt decreasing . of oxygen saturation and the paramedics were called. The Notes indicated Resident 1 was transferred to the GACH 2 at 10:10 pm. The notes indicated the primary physician was notified at 10:18 p.m. A review of the GACH 2 Emergency Documentation (ED) dated 2/11/2023 at 2:55 AM, indicated Resident 1 was brought in by ambulance due to shortness of breath and altered level of consciousness (ALOC, change from a person's usual state of being alert and aware). The ED Note indicated when the paramedics arrived at the facility (SNF), Resident 1 was on BiPAP with no oxygen supply and an oxygen saturation of 55%. Resident 1 was placed on non-rebreather mask and oxygen saturation increased to 100%. Resident 1 had no response to painful stimuli, was not moving extremities or following commands. The ED Note indicated on re-assessment Resident 1's mental status improved with eyes open and interacting. Resident 1 was admitted to the ICU for close monitoring. A review of the GACH 2 Discharge summary dated [DATE] at 11:01 PM, indicated Resident 1 remained stable in the ICU, receiving oxygen via nasal cannula during the day and BiPAP at night. The Discharge Summary indicated Resident 1 was discharged on 2/16/2023 to another facility. During a telephone interview on 2/23/2023 at 11:18 AM, Registered Nurse Supervisor (RNS 1) stated Resident 1 was re-admitted to the facility on [DATE] at around 5 p.m. RNS 1 stated Resident 1 was dependent on oxygen, and he called the RT within 10 to 15 minutes of Resident 1's arrival to set up the BiPAP. RNS 1 stated he placed Resident 1 on oxygen four liters by nasal cannula and continued monitoring Resident 1's oxygen saturation. At around 9:30 pm, RNS 1 stated Resident 1's oxygen saturation dropped to 75%. RNS 1 stated he increased the oxygen and Resident 1's oxygen saturation increased to 90%. RNS 1 stated the paramedics were called. During an interview on 3/9/2023, at 12:41 p.m. the Director of Nursing (DON) stated when Resident 1's oxygen saturation decreased, LVN 1 placed Resident 1 on BiPAP thinking that it would help Resident 1 before the paramedics arrive. The DON stated Resident 1 should have the non-rebreather mask instead, which would give a high flow of oxygen. The DON further stated the nursing documentation of what happened was not clear, as it lacks information such as Resident 1's alertness or responsiveness and did not show the whole picture of what happened. A review of the facility policy titled, Oxygen Administration, reviewed on 1/26/23 indicated after completing oxygen set-up or adjustment, the following information should be recorded in the resident's medical record: -The date and time that the procedure was performed -The name and title of the individual who performed the procedure -The rate of oxygen flow, route, and rationale -The frequency and duration of the treatment -The reason for prn administration -All assessment data obtained before, during and after the procedure -How resident tolerated the procedure. A review of the facility policy titled, First Aid Treatment, reviewed on 1/26/2023, indicated basic first aid intervention included (but is not limited to) interventions for the following situations which included choking and breathing emergencies. The policy indicated the goal of emergency intervention was to stabilize the resident and the situation until further treatment was available.