**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a lifesaving technique consisting of chest compressions and often combined with artificial ventilation used in emergencies to treat persons with ineffective heart pumping/beating and compromised breathing to improve blood perfusion throughout the circulatory system to vital organs, especially to the brain) for one of 2 sampled Residents (Resident 1) when Resident 1 was found unresponsive. This failure left Resident 1 without receiving (CPR), which was not in accordance with his choice for full treatment (to prolong life by all medically effective means), as indicated in his POLST (Physician Orders for Life-Sustaining Treatment). Findings: The clinical records of Resident 1 were reviewed. Resident 1's Face Sheet (summary of important resident information), Advance Directives (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity), POLST (Physician Orders for Life-Sustaining Treatment) and Order Summary Report all indicated Resident 1 had opted for Full Treatment or Full Code (a medical order indicating that the person should receive CPR when the situation warrants it). Review of Resident 1's Face Sheet (summary of important resident information), dated [DATE], indicated, he was re-admitted to the facility on [DATE], with diagnoses including a sacral (pertaining to the set of fused bones at the base of the spine below the lower back area of the pelvis) pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of long-term pressure, or pressure in combination with shear or friction), obstructive reflux uropathy [disorder to which urinary flow is obstructed in the urinary tract (body's drainage system for removing urine)] and hypotension (lower than normal blood pressure). The Advance Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) section of the face sheet indicated: Full Code (a medical order indicating that the person should receive CPR when the situation warrants it). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated a Brief Interview for Mental Status (BIMS, a cognitive assessment) score of 13, which meant he was cognitively intact. (0-7 points = severe cognitive impairment; 8-12 points = moderate cognitive impairment; 13-15 points = cognitively intact). Review of Resident 1's POLST Form, dated [DATE], indicated a box checked for Attempt Resuscitation/CPR and a box checked for Full Treatment. It contains dated signatures of both Physician 1 on [DATE], and Resident 1 on [DATE]. Review of Resident 1's Order Summary Report printed on [DATE] indicated, Active orders as of [DATE] . FULL CODE, Order Status: Active, Order Date [DATE]. Review of Resident 1's Record of Death received on [DATE] indicated, date of death [DATE] Hour 0500 (5:00 AM), Nurse present at time of death: name of [LVN A] (Licensed Vocational Nurse), Name of person notified: [name of Physician 1], Relationship to Patient/Resident: Physician, Attending physician notified by: [LVN A], Date and Hour: [DATE] 0545 (5:45 AM). Remarks: Resident expired peacefully in his sleep at 0500 on [DATE]. Notified [Name of Funeral Home] [Phone number of Funeral Home] . Called by [Signature of LVN A] . Mortician's Report; Received from [name of LVN D] The remains of: [Name of Resident 1] . Body released by: [Name of LVN D] at [DATE] at 0920 . Signed by [Funeral Home Staff]/Mortician, [Name of Mortuary], [Address of Mortuary]. Review of Resident 1's Nurse Notes with effective date: [DATE], at 07:31, indicated, Late Note: Nursing staff attempted to administer routine medication to resident. Resident was not responding to voice. This nurse tapped on his shoulder with no response. Nurse applied sternum stimulation (rubbing the bone in central part of the chest to test an unconscious person's responsiveness) and no response. Lungs auscultated (listened for airflow in the lungs) with no sounds heard. No heartbeat presented. Capillary refill (pressure applied to a finger to detect blood flow after releasing pressure) was not present. Complexation to the skin was pale and cold to touch. Request 2nd nurse in facility to verify and same results obtained from body. Resident expired at 0500 this morning on 3rd shift. Dr. [Name of Physician 1] primary physician, informed of resident status and aware. Administrator and DON (Director of Nursing) notified as well. Resident is his own responsible family. Friend [name of friend] number dialed but is not able to get a hold of. Orders to release body to mortuary obtained and carried out. [Name of Funeral Home] notified. Spoke to [name of staff]. Informed that mortuary will be at facility to pick up body after 0900 today. Report over to oncoming nurse . During an interview on [DATE], at 12:04 p.m., with Licensed Vocational Nurse B (LVN B), she stated she knew Resident 1 to be, alert, oriented, made his own decisions, was his own responsible party . Full Code. He died on [DATE] . On day shift on [DATE] . he was fine. Review of a document received [DATE] from Interim DON (INT-DON) regarding Resident 1 titled, Statement of [LVN A] on [DATE] at 1600 indicated, What happened? I (LVN A) was passing my meds (medications); when I arrived at the resident's room, I announced it was time for his medication. He usually responds to me; so, I went to the side of his bed and started talking to him; I called out his name and he did not respond to me. I then went to the other side of the bed and turned on the light. I touched him and he was cold to the touch. He did not wake up or respond. Then I did the sternum rub. He still did not wake up. I went to listen to his lungs and there were no sounds. I could not find his heartbeat nor his pulse rate. I noticed his capillary refill was not present. Why did you not perform CPR? I did not perform CPR because he was not breathing anymore. No life was in him. Were there any signs of declining during your shift? No, he was fine. When was the last time you interacted with the resident while he was alive? The last time I looked into his room, it was around 0400. I could see the glare from the television on his face; his eyes were open, and he had his remote in his hands - he was putting it on his table. Are you aware where the crash cart (a wheeled container carrying medicines and equipment for emergency resuscitations) is and how to call a Code Blue (used to indicate a patient requiring resuscitation or immediate medical attention)? Yes, I know where those things are, I have never had to do that here. But I know how to do it. Did you know the resident was Full Code? I did not know until after I called the doctor; I assumed he was DNR (do not resuscitate) because of his condition. Is your CPR current? Yes, it is good for 2 years; It expires [expiry date]. Is there anything you would do different next time? I will check the code status . Signed by [LVN A]; DSD and INT-DON. During an interview with the Interim Director of Nursing (INT-DON) on [DATE], at 12:12 p.m., when asked why Resident 1 was not given CPR she stated, Yes Ma'am, it was not done. When asked what should have been done, the INT-DON stated, Life saving measures should have been implemented right away . That's a patient's choice, he had the right to be Full Code . he designated that in his POLST. When asked if CPR was not done as per LVN A's statement and if there was a failure, the INT-DON stated, correct, to both questions. During an interview with LVN C on [DATE], at 1:15 p.m., when asked what she would do if a resident were Full code, LVN C stated, If I found someone unresponsive, I assess vital signs (V/S, essential body functions like heartbeat, pulse rate, temperature and blood pressure) and call a code on the Intercom so all nurses can come and help me regardless of day and time of incident. So, I will be in-charge since I was the one who found the patient unresponsive. I'll have a CNA (Certified Nursing Assistant) or myself start CPR; when code team (emergency medical response personnel) arrives, we could start oxygen (air we breathe to live), AED (automated external defibrillator, medical device to analyze a heart's rhythm, if necessary, deliver an electric shock to help the heart re-establish an effective rhythm). I would also assign a nurse to call 911 and assign a CNA or Nurse to wait by the door for EMS (emergency medical services staff) so they could come to the patient's room. We continue CPR (chest compressions, AED) until EMS tells us that we are relieved, and they will take over. When asked how to check if the patient is DNR or Full Code, LVN C stated there is a binder in every unit that has the Code Status, it has their POLST there as well . we also have our laptop on [the] Med Cart, in the EMR [name of electronic medical record] the code status is there . We notify the Provider (Physician), DON, Administrator, and family . this is taught to us usually monthly . we have nurse meetings every 2nd Tuesday of the month where they tell us what the expectations are and if the code status was updated . Station One is Post-Acute unit . every time a new patient comes, the Code Binder is updated. Station Two is Long Term Unit. Review of Facility policy titled In-Service Training, All Staff revised [DATE] indicated . 1) All staff are required to participate in regular in-service education. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. 5. Training methods and teaching materials are appropriate to the level of education and expected roles of those attending. During an interview with Physician 1 on [DATE], at 1:30 p.m., he stated, . if patient was doing okay at 4:00 a.m. and at around 5:00 a.m. was found unresponsive, the nurse should have initiated a Code Blue (code blue or code, used to indicate a patient requiring CPR or to indicate a patient requiring resuscitation or immediate medical attention) . The reality of the situation, even say patient died say 4 hours ago, she should have initiated a code and called 911. She is not a licensed person that can pronounce death. It's not her place to declare death . I did not pronounce the patient dead at 5:00 a.m. when she called. I wasn't aware it was an issue until . later I found out no code was done, and the patient was a full code. During an interview with the Director of Staff Development (DSD) on [DATE], at 2:07 p.m., she stated all the facility's LVN staff should know how to do CPR and should know whether their assigned residents are full code, or not. Review of Facility's Job Description for Position Title: Licensed Vocational Nurse (LVN), with Date written: [DATE] indicated, . Purpose: LVNs provide medical support to physicians, registered nurses and patients. They provide routine care, take vital information from patients, provide information about treatments and prescriptions and observe patient health.Responsibilities: . Observe patients under treatment to identify progress, side effects of medications etc. Monitor patients' condition .Requirements: Familiarity with skilled Nursing, safety and sanitation standards and procedures, .Current BLS (Basic Life Support - medical care used for patients with life-threatening illnesses or injuries, covers CPR but includes additional life-saving techniques that can help those experiencing cardiac arrest, respiratory distress, or an obstructed airway) Certification Required. According to the California Code of Regulations: Title 16 CCR § 2518.5. Scope of Vocational Nursing Practice. The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan and treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. Title 16 CCR § 2518.6. Performance Standards. (b) A licensed vocational nurse shall adhere to standards of the profession and shall incorporate ethical and behavioral standards of professional practice which include but are not limited to the following: (1) Maintaining current knowledge and skills for safe and competent practice . During an interview on [DATE], at 2:23 p.m. with LVN A, she stated, I was in the hallway passing meds, usually when I go in there, he (meant Resident 1) is alert and he responds. I went in there the TV was on. I called out his name, Mr. [Resident 1 name] here's your meds, usually he would respond, but he did not. I bumped the bed with my hip, my hands were full with meds and drink, no response . I went around the other side of the bed to pull the light, I noticed he was very pale, eyes wide open. So, I touched him, and he was cold. I was feeling the pulse, no pulse. I listened to his lungs with the stethoscope (medical instrument used to listen to sounds produced within the body), there was nothing then I did the sternum rub. LVN A was asked if she knew the code status and she stated, No, not at that time and that was my mistake, I should have checked that because he was going downhill, he was already weak, he had bedsores. There were times he wouldn't want his drink or care and would say 'leave, me alone, no I don't want that,' I didn't want him to be riled. LVN A was asked if she thought about doing CPR, LVN A stated, no because he had no more life, he was cold. LVN A was asked if she knew that, as an LVN, she could not pronounce death, LVN A stated, Now I am aware, I was a home health nurse . I guess it's different than what I thought. When LVN A was asked if she knew there is a Code Binder in the unit, LVN A stated, Yeah, no I did not look at that time . after the sternum rub, I called the CNA 'hey he passed away,' I let the Doctor (Physician 1) know . I texted him; he got the message, he said okay . I let the Administrator (ADMIN) know, I texted them all and the DON . The ADMIN said/texted, 'Was it expected?' I texted everything was fine during the shift until he was found unresponsive. When asked if the ADMIN asked her if they did CPR, LVN A stated, No. LVN A further stated, I called the Mortuary on his chart, informed the mortuary that he died . they did not pick up right away. LVN A was asked who pronounced Resident 1 dead, LVN A stated It was me I guess, the doctor (Physician 1) said okay on text . At this time the CNAs cleaned him up and prepared him for the mortuary . The body was in the room ready for pick-up for mortuary. I endorsed to the next shift nurse . I left the facility at 8:00 a.m. came back at 2:00 p.m. they (Facility) were telling me I need to redo my statement to make it clearer on my notes to reword it to make it understandable, I reworded it, but it is the same thing, why I didn't do CPR. When LVN A was asked if Physician 1 gave an order to release the body, LVN A stated, No, he said okay, so I wrote it as an order to send him out to mortuary. When he asked if she assumed it was an order, LVN A stated, Yes. LVN A confirmed there was no mention of CPR done and 911 was not called in her note. She stated, I feel bad that I didn't. I didn't focus that night . it takes a toll . I take the blame, I'm sorry. Record review of the Emergency Medical Record Progress Notes, dated [DATE], at 1500, indicated, Note/Text: Discharge/Death Summary, Dx (Diagnoses): CVA (cerebrovascular accident, STROKE, interruption of blood flow to the brain), BPH (Benign Prostatic Hyperplasia, enlarged prostate glands in men), HTN (Hypertension, high blood pressure), RA (Rheumatoid Arthritis, swollen painful joints), Hx CAUTI (history of catheter - associated urinary tract infection) and pneumonia (inflammation of the lungs) . Hospital Course . The patient was treated again with abx (antibiotics) and then sent back to [the skilled nursing facility's name] and admitted on 8/17. The patient was last seen on 11/22 at which time RN reported dysuria (painful or difficult urination) symptoms. UA (urinalysis, laboratory examination of a person's urine) ordered. On the morning of 11/29, I was informed by RN that the patient had passed away peacefully at 5 AM. Author: [Physician 1]. Review of Facility policy Emergency Procedure - Cardiopulmonary Resuscitation, Revised February 2018, indicated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS, type of care that first responders, healthcare providers and public safety professionals provide to anyone experiencing cardiac arrest, respiratory distress, or obstructed airway), including defibrillation, for victims of sudden cardiac arrest . If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a do not resuscitate (DNR) that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g. rigor mortis, stiffening of the joints and muscles of a body a few hours after death, usually lasting from one to four days) . If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR (do not resuscitate) or a physician's order not to administer CPR . if the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instruction until a CPR-certified staff member arrives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely discharge on e of three residents (Resident 1) when Resident 1 was discharged , due to non-payment, while the facility's business office actively sought a payor source for Resident 1's stay in the facility and when the resident's Medi-Cal (California's health care program which covers most medically necessary care) eligibility was pending. Resident 1 cried because she did not want to be discharged and was being discharged to a shelter against her wishes. Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her, and Resident 1 returned to the facility. The resident is currently residing in the facility with coverage provided by Medi-Cal. These failures resulted in an inappropriate discharge for Resident 1 and caused harm to the resident's mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with dressing and required physical help in part of bathing activity. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 3/15/23, indicated the resident required one-person limited assistance/supervision with ADL's. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility - cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn ' s disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated Resident 1 required supervision and set up help for ADLs including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program notes, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt . Review of Resident 1's social services progress notes, dated 4/10/23, one day before the resident was discharged , indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. There was no documentation the interdisciplinary team (IDT) discussed regarding Resident 1's discharge, to determine whether the resident was sufficiently independent to discharge or the resident agreed to be discharged to a shelter. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Patient has been doing well. She continues with knee and hip pain .A/P [assessment/plan]: 1. Debility - cont rehab 2. Knee, hip pain S/P fall- degenerative disease on imaging. Continue pain control .dispo [disposition]: cont rehab. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/25/23, indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with bed mobility, transfer, walking in the room, walking in the corridor, locomotion, dressing, and eating. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she was not familiar with the facility's discharge policies. She stated Resident 1's stay at the facility was not paid by her insurance. She stated Resident 1 was not appropriate for this facility. The SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. During a telephone interview, on 7/24/23 at 8:50 a.m., the BOM stated she was actively searching for a payor source for Resident 1. She stated she had a conversation with Resident 1, who informed her that someone was working on her Medi-Cal eligibility, so Resident 1 was updated to Medi-Cal pending. The BOM stated Resident 1 became eligible for Medi-Cal as of 4/24/23. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A ' facility-initiated transfer or discharge ' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. After the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. Based on interview and record review, the facility failed to safely discharge on e of three residents (Resident 1) when Resident 1 was discharged , due to non-payment, while the facility's business office actively sought a payor source for Resident 1's stay in the facility and when the resident's Medi-Cal (California's health care program which covers most medically necessary care) eligibility was pending. Resident 1 cried because she did not want to be discharged and was being discharged to a shelter against her wishes. Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her, and Resident 1 returned to the facility. The resident is currently residing in the facility with coverage provided by Medi-Cal. These failures resulted in an inappropriate discharge for Resident 1 and caused harm to the resident's mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23, indicated, on 2/15/23, the female resident was admitted to the facility with diagnoses including unspecified mood disorder, post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with dressing and required physical help in part of bathing activity. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 3/15/23, indicated the resident required one-person limited assistance/supervision with ADL's. Review of Resident 1's Physician's Progress Note, dated 3/20/23, indicated, debility – cont [continue] rehab [rehabilitation] 2. Knee, hip pain S/P [status post] fall-obtain x rays; normal exam; continue pain meds [medications], add Lidoderm patch [a local numbing medication to treat pain] Crohn's disease-h/o [history of] SBO [small bowel obstruction] resection [removal]; currently on 40 mg [milligrams, unit of measurement] prednisone [a medication to treat inflammation]; awaiting GI appt [appointment] . dispo [disposition]: cont rehab. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated Resident 1 required supervision and set up help for ADLs including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program notes, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt . Review of Resident 1's social services progress notes, dated 4/10/23, one day before the resident was discharged , indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing Care Needs , Activity Limitations , Treatment/Special Instructions , Nutrition/Diet Order , Physical/Occupational Therapy , and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. There was no documentation the interdisciplinary team (IDT) discussed regarding Resident 1's discharge, to determine whether the resident was sufficiently independent to discharge or the resident agreed to be discharged to a shelter. Also, there was no documented evidence Resident 1 was informed of continuing care after discharge. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Shelter A's website indicated services the shelter provides included the following: Every day of the year, we provide safe, overnight lodging, a shower and a listening ear to men who have no other place to go; A long-term recovery program for men who want to find a new path for life; and, At this time, we can offer lodging and showers to men only. Review of Resident 1's social services progress note, dated 4/12/23, the day after the resident was returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal, she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs . Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Patient has been doing well. She continues with knee and hip pain . A/P [assessment/plan]: 1. Debility – cont rehab 2. Knee, hip pain S/P fall- degenerative disease on imaging. Continue pain control . dispo [disposition]: cont rehab. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/25/23, indicated for Activity of Daily Living (ADL) Assistance, the resident required supervision and one-person physical assistance with bed mobility, transfer, walking in the room, walking in the corridor, locomotion, dressing, and eating. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview, on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated she was not familiar with the facility's discharge policies. She stated Resident 1's stay at the facility was not paid by her insurance. She stated Resident 1 was not appropriate for this facility. The SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m., with the DON and SSD, the DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. During a telephone interview, on 7/24/23 at 8:50 a.m., the BOM stated she was actively searching for a payor source for Resident 1. She stated she had a conversation with Resident 1, who informed her that someone was working on her Medi-Cal eligibility, so Resident 1 was updated to Medi-Cal pending. The BOM stated Resident 1 became eligible for Medi-Cal as of 4/24/23. During a telephone interview, on 7/24/23 at 10:51 a.m., the administrator (ADM) stated she did not ask whether the shelter was for males or females. She stated she assumed Shelter A was co-ed (open to or used by both men and women). During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility and she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A ' facility-initiated transfer or discharge' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or <[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. Resident 1's psychologist (psych, a medical doctor who specializes in mental health) referral (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) was not initiated as ordered, prior to the discharge; 5. Resident 1's Preadmission Screening and Resident Review (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI, mental, behavioral, or emotional disorder), developmental disability (DD, a group of conditions due to physical impairments or impairments in the areas of learning, language, or behavior), intellectual disability (ID, condition to describe a person with limitations in the ability to learn and function), or related condition requires specialized services such as referral to a mental health authority) Level I Screening was not done prior to admission or within 30 days of admission and a PASSR Level II evaluation was not completed; 6. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a homeless shelter. Resident 1 cried because she did not want to be discharged . Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her and Resident 1 returned to the facility. Prior to her discharge, Resident 1's mental and psychological status was not evaluated as her PTSD was not assessed, her thoughts of self-harm were not followed up, and her psych referral was not initiated. Resident 1 did not receive sufficient notice prior to her discharge and was being discharged to a shelter against her wishes. These failures resulted in emotional distress in Resident 1 and caused harm to her mental and psychosocial well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23 indicated, the resident was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self harm. States she does not have a plan but has self harmed in the past .Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's progress notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's physician order, dated 3/29/23, indicated, Per MD [medical doctor] start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t [related to] Anxiety Disorder, ADHD, and PTSD. There was no documentation that indicated Resident 1's psych referral was initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated staff documented that Resident 1 required supervision and set up help for activities of daily living (ADLs) including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program (activities that focus on increasing a person's level of functioning) note, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt (a device used to help a person transfer or walk safely) . Review of Resident 1's social services progress notes, dated 4/10/23, indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): .The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . Review of Resident 1's progress notes, indicated there was no documentation the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussed Resident 1's discharge including her thoughts of self-harm and PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS, Resident/Family Plan for Continuing Care, Community Services Desired, Nursing Care Needs, Activity Limitations, Treatment/Special Instructions, Nutrition/Diet Order, Physical/Occupational Therapy, and Activities were left blank. The section, Follow-up Instructions, Appointment, and Referral to were left blank. There was no documentation that indicated Resident 1's psych referral or appointment was set up. Review of the facility's census, dated 4/11/23, indicated Resident 1's bed was vacant. Resident 1's name was not listed on the census. Review of Resident 1's social services progress note, dated 4/12/23 after she returned to the facility, indicated, Conversation held in regards to [Resident 1's] Medi-cal [California's health care program which covers most medically necessary care], she stated her sister told her that as of today it is [in effect] and should be active in system within 24hrs .Res states she knows she reacted horrible to the leaving but it is related to her PTSD. Review of Resident 1's PASSR Level I Screening, dated 5/30/23, indicated, Result of Level I Screening: Level I - Positive. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder .? the responses were, Yes and anxiety disorder, adhd. There was no documentation that indicated Resident 1 had a PASRR Level I assessment prior to admission or within 30 days of admission. There was no documentation that indicated Resident 1 had a PASRR Level II evaluation. During a telephone interview, on 4/11/23 at 10:15 a.m., Resident 1 was crying and requested help because she did not want to be discharged . During an interview on 4/11/23 at 2:38 p.m., Resident 1 stated she was informed about a bed available at a shelter, but the shelter was not an option for her. She stated it was a men's shelter and they could not take her, so she returned to the facility. Resident 1 also stated she was still awaiting a GI (gastrointestinal) appointment and a psych appointment. During an interview, on 5/16/23 at 1:27 p.m., the facility's van driver (VD) stated she drove Resident 1 to Shelter A, with the director of nursing (DON) also present. She stated, [Resident 1] was crying when we were leaving. The VD stated the DON got out of the van to talk to someone in Shelter A and Resident 1 stayed in the van. She stated the shelter where they were going to drop off Resident 1 was for males, not females. During an interview, on 5/16/23 at 3 p.m., the director of nursing (DON) stated, [Resident 1] was hysterical and crying with anxiety because she did not want to leave [the facility]. The DON stated when they arrived at Shelter A, they found out the shelter was a men's only shelter. She stated the staff at Shelter A directed them to another shelter, but the other shelter also would not take Resident 1 because she was not able to walk or look for job placement. During an interview, on 5/23/23 at 12:05 p.m., Resident 1 stated she has complex PTSD (a mental health condition with similar symptoms as PTSD, but may include problems controlling emotions and feelings of worthlessness, shame and guilt) due to childhood and adult traumas, including the loss of her son and being gang raped. Resident 1 stated she was told she had to leave and the staff started grabbing her belongings, which upset her. She stated the SSD told her they found her a bed at a shelter, but stated she tried to explain that she was not able to go to a hall or large room with a lot of people, like a shelter. Resident 1 stated she was not able to even go into stores when there are too many people. Resident 1 stated when she was placed in the van, her mind just believed anything could immediately go wrong. Resident 1 stated when they got to the shelter, they found out it was a men's only shelter. She stated the day the facility discharged her made her mental health worse. Resident 1 was crying and stated she would rather die than go through that. During an interview, on 7/5/23 at 1:50 p.m., Resident 1 stated she has not had a psych referral yet and expressed the need for it. During an interview, on 7/5/23 at 2:30 p.m., the SSD stated Resident 1 mentioned claustrophobia (extreme or irrational fear of confined places) as a trigger for her PTSD. She stated she might have missed creating Resident 1's care plan for PTSD. During an interview on 7/5/23 at 2:44 p.m., the SSD stated Resident 1 had a care plan for depression, but it should have been for PTSD. The SSD stated she did not know anything about a psych referral for Resident 1 prior to her discharge. During an interview, on 7/12/23 at 12:07 p.m., the business office manager (BOM) stated Resident 1's insurance would not pay for her stay and the reason for this was not clear. She stated the facility needed to find another payor source to cover her stay in the facility. The BOM stated at one point, Resident 1 was not eligible for Medi-Cal, but someone was assisting the resident with the process, and it was being worked on. The BOM stated she was not aware the facility was trying to discharge Resident 1. She stated if a resident has no other form of payment, the resident should be given a 30- day notice prior to discharge. She stated during that time, the SSD and the resident should come to an agreement on the discharge location, to ensure a safe discharge. During an interview, on 7/12/23 at 1:48 p.m., Resident 1 stated she was trying to explain to the staff about her PTSD and her triggers. She stated being cornered is one of her triggers. Resident 1 disclosed that she had experienced sexual assault and had also lost her son, and she strongly felt the importance of keeping her belongings safe. The resident stated she informed the facility staff that they could not send her to a shelter because shelters are usually large rooms with many people. She stated she did not like the situation in shelters because she would not have any control over who she would be in there with and it would be difficult for her to guard her belongings. Resident 1 stated she explained to the facility that due to her being raped, she would not feel safe staying inside a shelter and would likely prefer to sleep outside if faced with that situation. During an interview and concurrent record review of Resident 1's nursing progress notes, on 7/12/23 at 2:14 p.m. with the DON and SSD, the SSD stated she was not aware of Resident 1's thoughts of self-harm on 2/21/23. She stated she was not informed, so she did not follow up. The DON stated she was unaware Resident 1 had PTSD. She stated when a resident comes to the facility with a diagnosis of PTSD, staff should ask about the resident's triggers. The DON stated Resident 1 should have a monitoring tool in place, which identifies the resident's triggers, and a routine order should be placed so staff can observe and look for any related behaviors. She stated it will be implemented now that it has been brought to their attention. The SSD stated she documented that Resident 1's PTSD on 4/10/23 but there was no documentation indicating the SSD had asked about Resident 1's triggers. The DON and SSD confirmed that Resident 1's PTSD was not discussed with the IDT. The DON stated when they took Resident 1 to Shelter A for discharge on [DATE], Resident 1 was having a breakdown. The SSD stated she was not aware of the physician orders for a psych referral until after Resident 1's discharge on [DATE]. She stated the nurses usually inform her about referrals but in this case, she was not notified. The SSD stated the referral process should have been initiated prior to Resident 1's discharge. During a telephone interview, on 7/24/23 at 10:35 a.m., the Administrator (ADM) confirmed that there was no admission PASSR completed for Resident 1 and there should have been. The ADM also stated since Resident 1's 5/30/23 PASSR Level I screening was positive, it should have been reported, and Resident 1 should have had a Level II PASRR evaluation. During an interview on 7/26/23 at 11:16 a.m., the assistant director of nursing (ADON) stated if a resident had thoughts of self-harm, the staff should stay with the resident and ask if they have an active plan. The staff should let the SSD, DON, and MD know, and monitor the resident for emotional distress. The ADON stated the nurse should document a change of condition assessment and monitor the resident for 72 hours or past 72 hours. She stated it should be discussed with the IDT. The ADON also stated that the facility should attempt to get psych services for the resident and document. The ADON confirmed there was no change of condition assessment regarding Resident 1's thoughts of self-harm. The ADON confirmed there was no documentation that indicated staff attempted to request for psych services for Resident 1. The ADON also confirmed there was no documentation that indicated the IDT discussed Resident 1's thoughts of self-harm. She stated it is important for the IDT to have a discussion in order to develop a strategy and plan of care for the resident. The ADON stated when the facility was discharging Resident 1, the resident was very upset. The ADON stated Resident 1 was very comfortable in the facility, she was going somewhere she did not know and that was not good for her. She stated the DON tried to calm Resident 1 down and went with her to the shelter, but they came back later on. The ADON stated there were no IDT notes that discussed Resident 1's discharge. She stated there was no IDT note that indicated that Resident 1 was agreeable to being discharged to a shelter. The ADON stated Resident 1's discharge was a planned discharge, so she should have been given a notice 30 days prior to her discharge. Review of the facility's policy, Behavioral Health Services, revised 2/2019, indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Review of the facility's in-service Education Record, dated 10/28/22, indicated staff was instructed on Behavior Management. The attached lesson plan included, Procedure for a Behavioral Change in Condition. Review of the facility's undated procedure, Procedure for a Behavioral Change in Condition, indicated, When a new behavior is identified in a resident the nurse will write a note in Nursing Note section describing the behavioral circumstances; Add to the Change of Condition Report - which will trigger 72 hour charting; Notify the physician's office of the change and explain nursing intervention techniques will be attempted to affect a change in the behavior; Notify the Director/Assistant Director in order for the Interdisciplinary Team (care plan team, family, consults, pharmacist) to write assessments. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, indicated the following: A 'facility-initiated transfer or discharge' means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Non-payment for a stay in the facility occurs when the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility and also may apply: a. When the resident has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or b. After the third party payer (including Medicare or Medicaid) denied the claim and the resident refused to pay for his/her stay. The facility will notify the resident of their change in payment status, and ensure the resident has the necessary assistance to submit any third party paperwork. The resident and his or her representative are given a 30-day advance written notice of an impending transfer or discharge from this facility. Review of the facility's undated position description for Director of Social Services indicated the essential functions included to develop and implement policies and procedures for the identification of medically related social and emotional needs of the resident and Participate in discharge planning, development and implementation of social care plans. According to Centers for Medicare & Medicaid Services (CMS, created to administer oversight of the Medicare Program and the federal portion of the Medicaid program), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States, dated 9/30/2009, indicated, States are required to have a PASRR program in order to screen all NF [nursing facility] applicants to Medicaid certified NFs (regardless of payer source) for possible MI [mental illness]/MR [mental retardation], and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR .All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level II PASRR evaluation. Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) and treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. Resident 1's thoughts of self-harm was not followed-up prior to discharge; 4. Resident 1's psychologist (psych, a medical doctor who specializes in mental health) referral (communication from one health care professional to another specialist requesting to evaluate someone's condition, provide a diagnosis, and/or provide treatment) was not initiated as ordered, prior to the discharge; 5. Resident 1's Preadmission Screening and Resident Review (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI, mental, behavioral, or emotional disorder), developmental disability (DD, a group of conditions due to physical impairments or impairments in the areas of learning, language, or behavior), intellectual disability (ID, condition to describe a person with limitations in the ability to learn and function), or related condition requires specialized services such as referral to a mental health authority) Level I Screening was not done prior to admission or within 30 days of admission and a PASSR Level II evaluation was not completed; 6. Resident 1 received a discharge notice one day prior to her discharge and became upset when informed she would be discharged to a homeless shelter. Resident 1 cried because she did not want to be discharged . Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. Shelter A was a shelter for males and did not accept her, another shelter also did not accept her and Resident 1 returned to the facility. Prior to her discharge, Resident 1's mental and psychological status was not evaluated as her PTSD was not assessed, her thoughts of self-harm were not followed up, and her psych referral was not initiated. Resident 1 did not receive sufficient notice prior to her discharge and was being discharged to a shelter against her wishes. These failures resulted in emotional distress in Resident 1 and caused harm to her mental and psychosocial well-being. Findings: Review of Resident 1's Order Summary Report, dated 4/11/23 indicated, the resident was a [AGE] year-old female and on 2/15/23, admitted to the facility with diagnoses including unspecified mood disorder, PTSD, Crohn's disease (a type of inflammatory bowel disease), attention-deficit hyperactivity disorder (ADHD, A chronic condition including attention difficulty, hyperactivity, and impulsiveness), and anxiety disorder. Resident 1's progress notes from an outside behavioral health service, which the resident used in the past, was obtained via Resident 1's verbal and written permission with the Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information form, signed by Resident 1 on 7/5/23. Review of the progress notes, dated 11/17/20, indicated the resident was diagnosed with PTSD, chronic, with panic attacks [an overwhelming feeling of anxiety that can cause symptoms such as sweating and shortness of breath]; MDD [major depressive disorder, a disease that causes persistently low or depressed mood, decreased interest in pleasurable activities, poor concentration, or appetite changes], recurrent, severe with anxious distress. Review of the progress notes, dated 12/1/21, indicated, Symptoms of PTSD [for Resident 1]: experience of trauma, hypervigilance [state of increased alertness to surroundings for potential threats or dangers], flashbacks, avoidance of reminders of trauma, nightmares. It also indicated Resident 1's problems include emotional dysregulation [inability to manage emotional responses], anxiety, agoraphobia [a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/22/23, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. It also indicated for Preferences for Customary Routine and Activities, the resident responded that it was very important to her to take care of her personal belongings or things and to have a place to lock her things to keep them safe. Review of Resident 1's nursing progress notes, dated 2/21/23, indicated, Resident reports having thoughts of self harm. States she does not have a plan but has self harmed in the past . Referred to SSD [social services designee] for f/u [follow up]. Review of Resident 1's progress notes, indicated there was no documentation that the SSD followed up regarding Resident 1's thoughts of self-harm. Review of Resident 1's nursing progress notes, from 2/22/23 to 2/24/23, indicated, nursing staff monitored the resident for her thoughts of self-harm for three days but, there was no change of condition assessment for the resident's thoughts of self-harm. Review of Resident 1's physician order, dated 3/29/23, indicated, Per MD [medical doctor] start referral for Psych [psychologist, a medical doctor who specializes in mental health] Eval [evaluation] r/t [related to] Anxiety Disorder, ADHD, and PTSD. There was no documentation that indicated Resident 1's psych referral was initiated or followed up. Review of Resident 1's care plans indicated the resident had a care plan for depression, initiated 4/4/23. There was no care plan that addressed Resident 1's PTSD. Review of Resident 1's Documentation Survey Report, documented by certified nursing assistants (CNAs), dated April 2023, indicated staff documented that Resident 1 required supervision and set up help for activities of daily living (ADLs) including bed mobility, dressing, locomotion, personal hygiene, toilet use, and transferring. Review of Resident 1's restorative program (activities that focus on increasing a person's level of functioning) note, dated 4/8/23, indicated, She is supervision assist for B [bilateral] UE [upper extremity]/LE [lower extremity] ROM [range of motion] and strengthening ex [exercises] and routine Ambulation using FWW [front wheel walker] and gait belt (a device used to help a person transfer or walk safely) . Review of Resident 1's social services progress notes, dated 4/10/23, indicated the social services designee (SSD) wrote, Writer spoke with res [resident] to let her know that a shelter bed has opened at [Shelter A]. [Shelter A's address and phone number]. Res became upset stating she has PTSD. Writer reminded res that facility is doing nothing for her as she is independent and doing all her own ADLS at this time. Res stated but I have not been walking. Writer asked, But you can walk, res stated yes with a walker. Writer offered res a walker to take with her. Writer reminded res that her insurance is no longer paying for her stay as she is independent res stated ok just give me some time. Review of Resident 1's Notice of Transfer or Discharge, dated 4/10/23, indicated [Resident 1] will be transferred/discharged to [Shelter A], [Shelter A's address] on 4/11/23 for the following reason(s): . The resident's health has improved sufficiently that the resident no longer needs the services provided by this facility. It also indicated Resident 1 signed on the notice indicating, This acknowledges that I received a copy of this Notice of Resident Transfer or Discharge, dated 4/11/23, the day she was discharged . Review of Resident 1's progress notes, indicated there was no documentation the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) discussed Resident 1's discharge including her thoughts of self-harm and PTSD. Review of Resident 1's Post-Discharge Plan of Care, dated 4/11/23, indicated the date of discharge was 4/11/23 and the resident was discharged to Shelter A. It indicated the reason for discharge was insurance non coverage and independent in activities of daily living. Under the section, POST-DISCHARGE NEEDS AND INTERDISCIPLINARY INSTRUCTIONS , Resident/Family Plan for Continuing Care , Community Services Desired , Nursing [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) monitored the residents' weights, identified the residents who had unplanned weight loss, assessed and discussed the cause of unplanned weight loss, updated the care plan with a measurable goal and interventions, and provided necessary and timely interventions to maintain acceptable weights of the residents, for three of three sampled residents (Residents 1, 2, and 3). 1. For Resident 1, in 12/2022, the resident had a 7.6 pounds (lbs) weight loss (4.9% in 30 days) and the IDT recommended weekly weights to monitor. Resident 1's weekly weight was not monitored as the IDT recommended and there was no documented evidence the IDT had followed up the resident's weight loss. In 2/2023, the resident had a significant weight loss, 16.2 lbs in 90 days, at 137.8 lbs, the registered dietitian (RD) recommended weekly weights, but the weekly weight was not repeatedly monitored. Resident 1's attending physician had inaccurate monthly weights of Resident 1 and when the RD identified Resident 1's significant weight loss, there was no evidence the IDT discussed and assessed the cause of Resident 1's significant weight loss and care planned regarding the resident's weight loss. The care plan regarding the resident's weight loss was not updated and developed with a measurable goal and actual interventions to prevent further weight loss or specify the acceptable weight range. These failures resulted in Resident 1's significant weight loss and continuous weight loss; 2. For Resident 2, there was no follow up by the IDT for four months after the resident's weight loss in January 2023. 3. The weekly weights of Residents 1, 2, and 3 were not monitored per care plan, IDT recommendations, and/or a physician order. This failure had the potential to result in being unable to identify the residents' weight loss, timely evaluate Residents 1, 2, and 3's complete nutritional status, and provide necessary interventions. Findings: 1. Review of Resident 1's face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions) and Type 2 diabetes (a condition which affects the way the body processes blood sugar). Resident 1's admission weight was 151.6 pounds (lbs). Review of Resident 1's Food and Nutrition Services Assessment, dated 8/24/22 indicated Resident 1's weight was 156 lbs, her usual weight was 150's, and the desired/goal body weight was stable weight. Review of Resident 1's Weight Change Note, dated 12/2/22 indicated, IDT met for monthly weight meeting .IDT recommends to cont. [continue] weekly weight, monitoring PO [by mouth] intake and follow up as needed. Review of Resident 1's short term: IDT monthly meeting care plan, dated 12/3/22 indicated current weight of 146.4 lbs. and weight loss of 7.6 lbs/4.9% in 30 days. A care plan intervention indicated, Weekly weights, date initiated 12/3/22. Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weights were taken weekly after 12/3/22. Review of Resident 1's Food and Nutrition Services Quarterly Assessment (Registered Dietitian [RD] Assessment), dated 2/27/23, indicated Resident 1's current weight was 137.8 lbs and the rate of unplanned weight loss was greater than 5 percent (%) in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. The assessment indicated, Unintended Weight Loss related to Psychological causes 2/2 [secondary to] depression as evidenced by weight loss of -16.2# [lbs] over last 90 days and -18.2# [lbs] over the last 180 days (significant weight loss). It also indicated, Please re-weigh, weigh weekly for 4 weeks. Will monitor nutrition intake and tolerance, and weight. Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weight was re-weighed. There was no documented evidence Resident 1's weights were taken weekly after 2/27/23. Review of Resident 1's potential nutritional problem care plan, dated 8/30/21, indicated, 2/27/23: 30 days: no data, 90 days: -16.2# [lbs] (-11.8%), 180 days: -18.2# (-13.2%). Significant weight changes . The nutritional problem care plan was revised on 2/27/23. The care plan's goal, also indicated, The resident will maintain adequate nutritional status as evidenced by maintaining weight within, no s/sx [signs and symptoms] of malnutrition, and consuming at least 50% of meals daily through review date. The care plan's Goal did not specify the range Resident 1's weight should be maintained within. There was no update or revision to the care plan's goal. The latest revision to the goal was 9/20/22. There was no update or revision to the care plan's Interventions. The latest care plan intervention was initiated on 12/3/22. Review of Resident 1's clinical record indicated there was no documentation that indicated the IDT discussed the RD's recommendation and Resident 1's significant weight loss identified in the 2/27/23 RD assessment. There was no documentation that indicated the IDT followed up on Resident 1's continued weight loss, addressed Resident 1's depression, identified the possible cause of Resident 1's weight loss, or discussed interventions or plan regarding Resident 1's weight. Review of Resident 1's Weights and Vitals Summary, dated 5/11/23, indicated the resident's most recent weights were 146.8 lbs on 12/8/22, 143.6 lbs on 12/29/22, and 137.8 lbs on 2/2/23. Review of Resident 1's Physician's Progress Note, dated 12/27/22 indicated, Wt [weight] 146.8 lbs- stable. Review of Resident 1's Physician's Progress Note, dated 1/30/23 indicated, Wt 143.6 lbs- stable. Review of Resident 1's Physician's Progress Note, dated 2/13/23 indicated, Wt 137.8 lbs- stable. Review of Resident 1's Physician's Progress Note, dated 3/20/23 indicated, Wt 137.8 lbs- stable., which was the resident's weight on 2/2/23. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, Wt 137.8 lbs- stable., which was the resident's weight on 2/2/23. During an interview on 4/11/23 at 2:04 p.m., the registered dietitian eligible (RDE) stated if he had a recommendation to add a resident to be weighed weekly, he would inform the administrator, charge nurse, and director of nursing. The RDE stated nursing staff is responsible for weekly weights and documenting the weekly weights. During an interview on 5/11/23 at 1:08 p.m., the MDS coordinator (MDSC) confirmed there was no weight input in Resident 1's electronic medical record after 2/2/23. The MDSC stated weights are documented on paper and then the previous director of nursing would enter the weights into the electronic medical record. During concurrent interview and record review, on 5/11/23 at 1:30 p.m., the MDSC stated Resident 1's weights were taken monthly and provided paper documentation of Resident 1's weights. The documentation indicated Resident 1's weight was decreasing at 137.6 lbs in March 2023, 133.8 lbs in April 2023, and 133.2 in May 2023. The MDSC confirmed there was no documentation Resident 1's weights were taken weekly after the RD's 2/27/23 assessment. During an interview on 5/23/23 at 11:45 a.m., the MDSC confirmed there were no new interventions added to Resident 1's potential nutritional problem care plan after 12/3/22. The MDSC stated any intervention could have been added at any time to address Resident 1's weight loss. During an interview on 5/23/23 at 11 a.m., the director of nursing (DON) stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 11:43 a.m., the DON stated in the past, IDT weight meetings were held by the dietary supervisor and involved all department heads, including the dietitian, DON, assistant DON, MDSC, and restorative nursing assistant. The DON stated she did not know how often IDT weight meetings were held. During an interview on 5/23/23 at 11:45 a.m., the MDSC stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 1:08 p.m., the dietary supervisor (DS) stated there was no IDT meeting that addressed resident weights since March 2023. During a telephone interview on 5/23/23 at 12:42 p.m., Resident 1's physician (MD) stated she was aware Resident 1 had gradual weight loss in February 2023 but was not sure Resident 1 was continuing to lose weight. During an interview with the registered dietitian (RD) on 5/25/23 at 12:50 p.m., the RD stated he would expect Resident 1 weekly weights to be done if it was a care plan intervention or an RD recommendation. The RD stated adding a resident on a list to be weighed weekly does not require an MD order. He stated it is within an RD's scope to add a resident to weekly weights. The RD stated that it falls under nursing to make sure the weights are being taken. He stated an RD not having the most updated weight would affect an RD's assessment. The RD also stated that it was important to work with the IDT. He stated there should have been documentation of an IDT discussion regarding Resident 1's weight. The RD confirmed Resident 1's care plan did not specify what Resident 1's weight should be maintained within. He stated the care plan should have a specific goal that is measurable, typically a target body mass index (BMI, a measure of body fat based on height and weight) range or a target weight range. The RD stated in the 2/27/23 RD assessment, after Resident 1's weight loss, there was no specific calculations for calorie, protein, or fluid needs and there was no target weight range indicated. During an interview on 6/6/23 at 1:18 p.m., the administrator (ADM) confirmed Resident 1 did not have weekly weights taken because there was no physician's order for weekly weights. During an interview and concurrent record review on 6/6/23 at 4 p.m., the ADM confirmed there was no documentation that the IDT discussed Resident 1's weight loss after 12/2/22. The ADM confirmed the last IDT note was on 12/2/22 and the note indicated the IDT would follow up as needed. The ADM stated if the RD were to review information and identify issues, then the IDT should follow up at that time. The ADM stated there were no nursing notes or IDT documentation regarding Resident 1's weight loss identified in the 2/27/23 RD assessment. The ADM also stated there was no documentation by the IDT regarding Resident 1's depression. The ADM confirmed there should have been some type of discussion and documentation by the IDT regarding Resident 1's weight loss after the 2/27/23 RD assessment identified significant weight loss. 2. Review of Resident 2's face sheet indicated he was admitted to the facility with diagnoses including severe sepsis with septic shock (serious infection that can cause organ failure and low blood pressure). Review of Resident 2's Weights and Vitals Summary indicated his weights were 189 lbs on 12/29/23, 184.8 lbs on 1/5/23, 178.4 lbs on 1/12/23, 175 lbs on 1/19/23, and 172 lbs on 2/2/23. Review of Resident 2's Weight Change Note, dated 1/13/23, indicated the resident had a 6.4 lbs weight loss in one week and the IDT will continue to monitor and follow up as needed. Review of Resident 2's Weight Change Note, dated 1/23/23, indicated the resident had a 3.4 lbs weight loss in one week and the IDT would continue to monitor and follow up as needed. Review of Resident 2's Food and Nutrition Services Quarterly Assessment, dated 3/21/23, indicated the resident's most recent weight was 172 lbs, documented on 2/2/23. The assessment indicated the weight history was No updated weight, unable to calculate weight changes. The assessment indicated, Documented by [RDE] and was signed by the MDSC, who is a licensed vocational nurse (LVN). Review of Resident 2's Food and Nutrition Services Assessment, dated 4/4/23, indicated the resident's most recent weight was 172 lbs, documented on 2/2/23. The assessment indicated, Documented by [RDE] and was signed by the MDSC, an LVN. Review of Resident 2's physician orders indicated an order, dated 4/8/23, for weekly weight one time a day every Monday. There was no documented evidence Resident 2's weights were taken weekly after 4/8/23. Review of Resident 2's Medication Administration Record for April 2023 and May 2023, indicated the order weekly weight one time a day every Monday was not signed as administered on 4/17/23, 4/24/23, 5/1/23, and 5/8/23. During concurrent interview and record review on 5/11/23 at 1:30 p.m., the MDSC confirmed there was no documentation Resident 2's weights were monitored weekly in April and May. Review of the facility weights for May 2023 indicated Resident 2's weight was 162. There was no documentation that the IDT discussed Resident 2's weight from February 2023 to May 2023. During concurrent interview and record review, on 7/7/23 at 10:30 a.m., the RD confirmed the 3/21/23 and 4/4/23 Food and Nutrition Services assessments utilized Resident 2's weight on 2/2/23. The RD stated the assessments would not be accurate and Resident 2's weight should have been taken. The RD also confirmed the assessments were documented by the RDE and signed by an LVN (MDSC). The RD stated if an assessment was documented by an RDE, the assessment should be monitored and signed by an official registered dietitian. During an interview, on 7/10/23 at 10:25 a.m., the RD confirmed there was no IDT discussion regarding Resident 2's weight between February 2023 and May 2023. 3. Review of Resident 3's face sheet indicated she was admitted to the facility with diagnoses including Type 2 diabetes and hypertension (high blood pressure). Review of Resident 3's Weights and Vitals Summary, dated 4/11/23 indicated her last recorded weight was 121 lbs on 2/2/23. Review of Resident 3's Food and Nutrition Services Assessment, dated 2/13/23, indicated Resident 3 had a change in condition and had a slight decrease in intake by mouth. The assessments indicated the nutritional monitoring and evaluation was Will monitor weekly weight, dietary intake and tolerance. Review of Resident 3's clinical record indicated there was no documented evidence Resident 3's weights were taken weekly after 2/13/23. During concurrent interview and record review on 5/11/23 at 1:30 p.m., the MDSC stated Resident 3's weights were taken monthly. The MDSC confirmed there was no documentation Resident 3's weights were taken weekly. Review of the facility's policy, Weight Assessment and Intervention, revised 3/2022 indicated the following: - Residents are weighed upon admission and at intervals established by the interdisciplinary team . - The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe b. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe c. 6 month - 10% weight loss is significant; greater than 10% is severe - Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight chance has been met. The evaluation includes the resident's calorie, protein, and other nutrient needs compared with the resident's current intake. - The physician and the multidisciplinary team identify conditions and medications that may be causing weight loss. - Individualized care plans shall address the identified causes of weight loss, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the comprehensive, person-centered care plan includes measurable objectives and timeframes and the interdisciplinary team reviews and updates the care plan when the desired outcome is not met. Review of the facility's policy, Care Planning - Interdisciplinary Team, revised 3/2022, indicated the interdisciplinary team is responsible for the development of resident care plans and the IDT includes but is not limited to the resident ' s attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services staff, the resident and/or the resident's representative and other staff as appropriate or necessary to meet the needs of the resident.