**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 37 residents reviewed. (Resident #105) The findings include: Resident #105 On 1/27/25, during the initial tour, Resident #105 was found to be unavailable for interview. When asked about Resident #105's whereabouts, staff stated that she was currently in the hospital. Upon record review, it was discovered that Resident #105 was transferred to the hospital on 1/24/25 due to abnormal lab readings. Resident #105 was admitted to the hospital for further care and treatment and was diagnosed with respiratory failure secondary to worsening of urinary tract infection. Upon further review of the medical record, Resident #105 was also admitted to the hospital on [DATE] - 4/17/24, 5/11/24 - 5/20/24, 5/30/24 - 6/6/24, 7/6/24 - 7/12/24, and 1/8/25 - 1/13/25 with abnormal vital signs of tachycardia and abnormal respirations, and altered mental status. Admitting diagnoses for each hospitalization revealed worsening urinary tract infections and sepsis. On 1/29/25 at 1:40 pm, an interview was conducted with Staff Member C, a Certified Nursing Assistant (CNA). CNA C stated she had worked at the facility for a year now. She stated she works with Resident #105 with her morning activities of daily living. Staff C reported that the resident has been sick the last several weeks and has not wanted to get up to her wheelchair. Staff C stated she informed the nurse that the resident was not feeling well. An interview with Staff Member B, a Licensed Practical Nurse, was performed on 1/29/25 at approximately 2:00 pm, Nurse B revealed that the facility process for a resident with a change in condition is for the nurse is to assess the resident, and notify the physician and the supervisor. If we receive orders from the physician, the nurse will implement the orders. Staff member B stated that they use the Situation, Background, Assessment, Recommendation (SBAR) form to keep track of assessments and recommendations. Staff Member B stated that if a person is sent out to the hospital, a transfer packet is also done, with the bed hold notice, transfer sheet, EMS sheet for need of transport, and it is documented electronically under assessments. An interview with Staff Member D, the Registered Nurse (RN) unit manager, was completed on 1/29/25 at 2:30 pm. She was asked if the SBAR was an expectation of the nurses to complete when there is a change in a resident's status. Staff member D stated it is the expectation to complete a SBAR when a resident has a change in condition and when they are transferred to the hospital. However, some staff nurses will put in a communication note, or a progress note instead of an SBAR assessment. On 1/29/25 at 3:00 pm, an interview with the Director of Nursing (DON) was performed. She confirmed that a SBAR assessment is to be completed by nursing staff when a change in condition is observed. A transfer packet is also to be completed on all residents when there is a change in condition that requires them to be transferred to the hospital for further treatment. The DON was asked if a SBAR assessment was completed on Resident #105 prior to being transferred out to the hospital. The DON stated that the resident has had several hospitalizations, but she was unsure if an SBAR was completed. The DON confirmed that it was her expectation that the nurses complete an SBAR assessment for each resident when a change occurs. The DON was then asked what measures are used to prevent hospitalization of a resident with a urinary tract infection. The DON stated they encourage the resident to drink fluids, call the physician if the resident does not show improvement of symptoms, provide peri-care for residents who are incontinent and dependent on staff, and implement probiotics and medications as prescribed by physician. The DON was asked if these measures were implemented for Resident #105 with each hospitalization. The DON stated Resident #105 refused to get up out of bed and always fussed about not getting the therapy she needed. The DON stated, Her family was always complaining about something. I have a grievance in the book in regard to her therapy, but she refused to participate when the therapist went to work with her. The DON stated there was a SBAR assessment completed for this last hospitalization on 1/24/25. The DON was asked if one was competed on the other hospitalizations in April, May, and July of 2024. The DON stated that she did not see one, but the nurses could have put a progress note in about it. The DON revealed a progress note written on 5/30/24, 7/6/24, and on 1/8/24 indicating a change in Resident #105's status. Upon further record review, Resident #105 was admitted to the facility on [DATE] and was diagnosed with a urinary tract infection on 4/17/24. On 6/6/24, Resident #105 was noted to have a new diagnosis of Extended spectrum beta lactamase (ESBL) resistant urinary tract infection. On 1/30/25 at approximately 10:34 AM, an interview was completed with the Infection Control Preventionist (ICP). She stated she tracks and trends when a resident is admitted to the facility with an infection or if they acquire an infection while here at the facility. She reviews the physician orders every morning in clinical meeting, and reviews the progress notes for the last 24 hours to see if a resident has documented symptoms of a possible infection. She states she reviews the facility map for patterns of any infections and showed a facility map colored coded by types of infections. When asked about the response if a pattern in one unit reveals an increase of urinary tract infections (UTI's), she stated she would bring up the concern to the clinical team and monitor for handwashing and performance of proper peri-care. She stated they will do staff training with the staff nurses and CNAs on that unit when a pattern of infections is present. She was asked about any tracking and trending related to Resident #105 to review her infections and hospitalizations. On 1/30/25 at approximately 12:15 PM, the ICP provided a handwritten form of Resident #105 hospitalizations which reveals the resident was diagnosed with a UTI when admitted to the hospital on [DATE], 5/11/24, 5/30/24, 7/6/24, and 1/8/25 and had no prior antibiotic therapy. (photographic evidence obtained) A review of the care plan for Resident #105 reveals she is at risk for urinary tract infections with history of ESBL. Care plan goal states that the resident will have no complications of UTIs and will minimize risk for complications for worsening UTIs through next review date. Resident #105 was hospitalized six times with in the last year related to worsening of urinary tract infections.

Based upon observations, interviews, and record reviews the facility failed to provide care and services to prevent further decrease in range of motion for 1 of 1 residents reviewed for range of motion issues. (Resident #99) The findings include: On 1/27/25 at approximately 11:00 AM, an observation of Resident #99 revealed contractures of bilateral hands. Resident #99 had hand splints laying on top of the refrigerator at his bedside. At approximately 3:30 pm, the resident was observed lying in bed again with no splints to bilateral hands. Bilateral hand splints are observed to still be on top of the refrigerator at bedside. Resident #99 was resting with his eyes closed. A record review at 3:45 pm on 1/27/25 revealed a physician's order for splints to bilateral hand/wrist to maintain neutral wrist alignment. Wear 3-5 times a week for 3-6 hours a day. On 1/28/25 at approximately 9:00 am, the resident was lying in bed with the head of the bed elevated at approximately 60-70 degrees. An oxygen nasal cannula was observed on the resident with staff at bedside assisting Resident #99 with breakfast due to contractures of bilateral hands. Resident #99 was awake and alert and denied having pain or discomfort at this time. Once again, the bilateral hand splints werelaying on top of the refrigerator at bedside. At 10:00 am, Resident #99 was laying in bed awake and alert. This surveyor asked about his hand contractures. He revealed that he had a stroke and is unable to use them. Resident #99 stated he is not getting therapy services currently. When asked if he wears his hand splints every day, he stated, No they don't put them on me. The resident demonstrated that he is unable to open his hands and extend his fingers when asked. At 1:00 pm, Resident #99 again stated that no one comes in to apply his hand splints or assist with range of motion exercises. Bilateral hand splints were observed on top of the refrigerator at bedside. At 4:00 pm, the bilateral hand splints were still observed on top of the refrigerator at bedside. On 1/29/25 at approximately 8:30 am, 12:30 pm, 2:00 pm, and at 4:00 pm, observations of Resident #99 revealed bilateral hand splints were not applied to Resident #99's hands and wrist. Bilateral hand splints were observed on top of the refrigerator at bedside during each observation throughout the day. Upon review of the medical record on 1/28/25 at 11:00 am, Resident #99 was found to have a physician order for a restorative program for range of motion and hand splints. Resident #99 has a diagnosis of bilateral hand contractures, knee contractures post CVA (stroke), dated 2/11/2023. Upon further record review, Resident #99 was on restorative program services. Documentation shows services were provided in November 2024 on the 4th, 5th, 8th, 11th, 12th, and the 13th for 15 minutes each visit. No documentation was observed for the month of December 2024. January 2025's restorative documentation reveals that the resident received services on the 2nd, 3rd, 6th, 7th, 8th, 9th, 13th, 14th, and the 16th. Resident #99 is care planned (initiated on 6/11/2024) for limited mobility related to contractures of upper and lower extremities with the goal that Resident #99 will remain free of complications related to immobility . On 01/29/25 at 12:40 PM, an interview with the Assistant Director of Nursing (ADON) was performed about the restorative program. She stated that there is a Certified Nusing Assistant (CNA) that does all the splinting and range of motion for residents on restorative care. The ADON stated that they just hired a new person to assist with restorative programs but this person has not started yet. An interview with the Director of Nursing (DON) on 1/29/25 at approximately 1:00 pm revealed that the therapy manager is over the restorative program at this time. The DON stated that, if the Restorative Nursing Aide (RNA) is not in facility, then the nurses and CNAs on the unit are expected to carry out the program. The nurse then documents on the TAR (treatment administration record) and the CNAs document on the plan of care (POC) under task. The DON reviewed Resident #99's range of motion exercises and application of splints to bilateral hands and wrist and acknowledged that no task for restorative was found in the POC. The TAR noted that a nurse signed off indicating that the splints had been applied on 1/28/25 and 1/29/25. She acknowledged that the splints and exercises were not being consistently done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide proper care and services for 1 out of 2 residents reviewed for hemodialysis services. (Resident #50) The findings include: On 01/27/25 at approximately 12:30 pm, Resident #50 was observed sitting in a wheelchair in his room. Resident #50 revealed that he just returned from dialysis treatment. He denied having any pain or discomfort. He stated he receives dialysis treatments on Mondays, Wednesdays, and Fridays from early in the morning and until around lunch time. Upon further interview with Resident #50, he voiced concerns in regard to a few weeks ago, after my treatment when I got back, my arm was hurting pretty bad. Resident #50 rubbed his right upper arm with his left hand and pulled his shirt sleeve up and to show his dialysis shunt site. He stated he informed the nurse of the pain. He stated the nurses did nothing in regards to the pain. He stated the nurses did not check his shunt site. When asked if he informed the dialysis center upon return, he responded, No I had to go to the hospital a few days later. On 1/27/25 at approximately 3:00 PM, the record review revealed no dialysis orders at all. Upon further review, the facility has no communication record to or from the dialysis center. The progress notes and nurse documentation revealed a progress note dated 12/23/24 stating that a family member requested Resident #50 be sent to hospital due to complaints of pain to his right arm. The nurse assessed Resident #50 and medicated Resident #50 with pain medication. The nurse documented that the bruit and thrill are present (phrases indicating blood flow occurring over a fistula site). On 12/24/24, Resident #50 continued to voice complaints of pain to the right upper arm and once again Resident #50 is medicated for pain. However, no assessment of the arteriovenous (AV) shunt was documented for two shifts. On 12/25/24, Resident #50 continued to voice complaints of pain to the right upper arm and once again Resident #50 was medicated for pain on the first shift with no assessment documented of the dialysis shunt site. On 12/25/24 at 06:30 pm, Resident #50 was observed in bed crying. When the nurse questioned Resident #50, he stated that he wanted to go to the hospital because his right arm is hurting. He stated the area to his dialysis had a pain radiating down his entire arm. He stated, on a scale of 1-10, that his pain is a 10. The resident was medicated with PRN pain medication and he stated that the medication was not effective. Emergency Medical Services were called at this time. Resident #50 was admitted to the hospital on [DATE]. After his transfer to the hospital, he underwent a surgical procedure to declot his Arteriovenous fistula. On 01/28/25 at 4:52 PM,an interview with the Director of Nursing (DON) was performed. The DON stated that dialysis communication sheets should be scanned into the electronic medical recors and, if they are not there, they can be found in the resident's medical paper chart. The DON stated that all residents receiving dialysis treatment have orders for what day the resident attends dialysis, where they go for dialysis treatments, and to monitor site prior to treatment and post treatment. The DON stated that nurses assess the resident before leaving for their treatment and assess again after the resident returns from treatment. However, the DON was not able to locate any physician orders or documentation of assessment prior to dialysis treatment and post dialysis treatment when Resident #50 returned to the facility. The DON located a communication sheet under the miscellaneous section of the paper chart from November 2024 and one from early December 2024. The DON acknowledged that Resident #50 should have orders to monitor what days he goes to dialysis, where he goes to receive dialysis, monitor for symptoms of infection at the dialysis fistula site, and documentation of bruit and thrill at the dialysis fistula site. A record review of Facility policy, End Stage Renal disease states, Care of a resident with End stage renal disease reveals residents with end stage renal disease will be care for according to currently recognized standards of care. Staff caring for residents with end-stage renal disease shall be trained in the care and special needs of these residents. Education and training of staff include specifically: the nature and clinical management of ESRD including infection prevention and nutritional needs. The type of assessment data that is to be gathered about the resident's condition on a daily pr per shift basis. How to recognize and intervene in medical emergencies such as hemorrhages and septic infections. Upon reviewing education records no education training has been completed related to Residents with End Stage Renal Disease and the care they receive.

Based on observation, record review and interview, the facility failed to provide needed medications as ordered for 2 of 5 residents sampled. (Resident #543 and #69) The findings include: Resident #543 On 1/27/25 at approximately 1:20 PM CST, Resident #543 stated she was in pain and but had not received her pain medication all weekend. She was observed in a fetal position and was having a hard time talking but kept saying, it hurts, it hurts. On 1/27/25 at approximately 4:28 PM CST, Staff J, a Registered Nurse (RN), stated during an interview that the reason that Resident #543 was in so much pain was because the facility had run out of her pain medication. Per the medical record, her order was for HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, Give 1 tablet by mouth as needed every 8 hours for pain. Based on the Medication Administration Record (MAR), Resident #543 did not receive her pain medication on January 24, 25, 26 or 27, 2025, even though the facility logged her pain level each time as a 9 on a 1-10 scale. On 1/27/25 at 5:06 PM, Staff J was asked why the resident was out of medication. Staff J stated, The only reason I can think of is someone forgot to renew the order. When asked if the facility had an emergency medication supply, she stated, We do, we have a Pyxis machine. She stated that Staff H, also an RN, was her nurse all weekend and she had no idea why Staff H did not get a code for the Pyxis since Resident #543 was in pain. On 1/28/25 at 5:05 PM, during an interview with the Director of Nursing (DON), she was asked if it was not acceptable for a medication to run out. She stated that staff had access to after hours doctors for a reason and, if they could not get the order, they know to call her and she will get it done. She also stated, We have emergency meds for a reason. On 01/29/25 at 10:34 AM, the DON in a follow up interview stated that the order states the medication was routine and they should have given the medication every 8 hours whether she was in pain or not. Staff also should have notified someone that they were out of the medication. More importantly, staff should not have run out of the medication. On 1/29/25 at 12:04 PM Staff F, also an RN, and Staff G, a Licensed Practical Nurse (LPN), were interviewed. Staff F stated she was not sure why the medication was not ordered, and that it was the responsibility of Staff H, who worked that weekend. Staff G stated she works with Resident #543 and was not aware that Resident #543 was out of pain medications. On 1/29/25 at 2:09 PM, an interview was held with Staff H, who worked with Resident #543 during the weekend and marked the medication as not available on the first day it ran out. She stated she was waiting for Monday to have the prescription signed. When asked why the emergency doctor was not called, she stated, I did not know this facility had access to after-hours doctors. Resident 543's Care Plan, dated 2/23/25, states for pain management the interventions include, administer pain medications as ordered and anticipate the residents need for pain relief and respond immediately to any complaint of pain. Resident #69: During an observation of Resident #69 on 01/28/25 at approximately 12:10 PM, Resident #69 was in the hallway sitting in her wheelchair. The residents' eyes appeared droopy, red, and irritated. On 01/28/25 at approximately 2:12 PM, Resident #69 was obsereved still in her wheelchair in the day area with no changes to her eyes. On 01/28/25 at approximately 2:28PM, Resident #69 was observed requesting medication for a headache. On 1/29/25 at approximately 8:45 am, Resident #69 was observed in the hallway sitting in her wheelchair again with noticeably red eyes. On 1/29/25 at approximately 4:02 PM, Resident #69 was observed in her room sitting in a wheelchair and again both eyes appeared red and irritated. On 1/28/25 at approximately 12:10 PM, when asked if her eyes hurt or were itchy, Resident #69 nodded yes. On 1/29/25 at approximately 8:45 am, when asked if her eyes hurt or were itchy, Resident #69 again stated yes. On 1/29/25 at approximately 11:45 AM during an interview with Staff I, a licensed practical nurse (LPN), the LPN verified Resident #69 had an as needed (PRN) eye drop medication (Systane Gel 0.4-0.3%) with an order that read, instill 1 drop in both eyes as needed for RED EYES THREE TIMES A DAY. The LPN verified that the medication was in the drawer and presented a brand new unopened box of Systane gel dated in black marker 01/28/25. The LPN was asked if Resident #69 is assessed for eye redness routinely, and the LPN stated she was. Upon review of Resident #69's physician orders, it was noted in the electronic medical record (EMR) that Systane Gel 0.4-0.3 % Instill 1 drop in both eyes, as needed for RED EYES THREE TIMES A DAY was placed on 06/20/2022. According to the EMR, the last dose of Systane gel was administered on 02/19/2024. (Photographic evidence obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and policy review the facility failed to obtain the results and promptly notify the provider of an abnormal urine culture resulting in a delay in treatment for 1 of 3 sampled residents reviewed for urinary tract infection. (Resident #2) The findings include: A review of Resident #2's paper and electronic medical record revealed the resident was examined by the Advanced Practice Registered Nurse (APRN) on [DATE] at 5:45 PM. The examination note revealed the family was concerned about the resident having increased drowsiness during the day and the facilty nurse reported some episodes of tachycardia. Respirations were elevated and even while resting. She was noted as continuing to decline. The current plan indicated orders for laboratory studies to include urinalysis with culture and sensitivity, comprehensive metabolic panel, platelets, magnesium, complete blood count, thyroid stimulating hormone, and a chest x-ray. Review of nursing notes: • The nurse's notes dated [DATE] indicated the labs were obtained that morning. • The nurse's notes dated [DATE] indicated the urine culture results revealed contamination and would need to be obtained again. • The nurses note dated [DATE] indicated another urinalysis for culture and sensitivity was obtained and sent to the laboratory at the hospital. The record revealed the resident received Bactrim DS antibiotic by mouth daily since her admission on [DATE] for urinary tract infection prevention. • The nurse's notes dated [DATE] at 7:00 PM indicated the resident had a temperature of 99.7. The family visiting reported resident had an occasional cough and was not feeling well. • The nurse's notes dated [DATE] at 9:00 PM indicated the resident had a non-productive cough, a temperature of 99.4, and the resident was hallucinating about speaking to her mother. The physician was contacted and advised to retest the resident for COVID-19 in the morning. The resident was tested for COVID-19 on the morning of [DATE] and was negative. • The nurse's notes dated [DATE] at 1:00 AM indicated the resident continued to have a non-productive cough and a temperature of 99.0 with continued hallucinations of speaking to her mother and father. • The nurses note dated [DATE] at 2:00 PM indicated the resident had been extremely fretful and the resident's daughter reported she had been calling out to past family members, awaiting a response from the physician. A physician order dated [DATE] indicated send resident to the hospital. • Review of the resident record on [DATE] during the survey revealed no result from the urinalysis culture obtained on [DATE]. The facility contacted the laboratory on [DATE] and obtained the result of the urinalysis culture dated [DATE]. Review of the urinalysis culture report dated [DATE] revealed the urine was positive for Escherichia coli and Proteus mirabilis and both organisms were resistant to Bactrim DS. The electronic culture report indicated it was reviewed by the APRN on [DATE] at 8:26 AM. The record revealed no additional antibiotic or treatment was ordered for the positive urine culture while the resident was in the facility. A review of the resident's hospital records dated [DATE]-[DATE] revealed a discharge summary by the physician dated [DATE]. The discharge summary indicated the resident was admitted to the hospital on [DATE] and expired in the hospital on [DATE]. The admission diagnoses were: altered mental status, COVID with concomitant pneumonia, hypoxia, urinary tract infection, coronary artery disease, and anemia. The discharge summary indicates the cause of death was presumed sepsis of a urinary source coupled with COVID positive pneumonia and a background history of Alzheimer's dementia. She was admitted , placed on Maxipime (an antibiotic) in addition to treatment with remdesivir (a medication for treatment of COVID-19) and some intravenous fluids. She had been placed on oxygen and ultimately required more of that as her stay progressed. Urine cultures returned positive for multiple organisms including Escherichia coli and Proteus. Eventually after some discussion, the family decided to make her simply care and comfort measures. Review of the hospital admission history and physical documented by the physician [DATE] revealed the resident has been deteriorating fairly rapidly over the last 4 to 6 months. According to family, within the last 2 or 3 days, she had substantial changes with altered mental status and not being able to recognize family, which was unusual for her. She had not been eating at all or taking any fluids. Of note, her roommate had tested positive for COVID, but for 3 consecutive days Resident #2 had not. Nonetheless, upon arrival to the Emergency Room, she was found to be altered with positive COVID and urinary tract infection and she was admitted for management, oxygenation, and intravenous antibiotics. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:09 PM. The DON stated the facility staff called the lab on [DATE] to obtain a copy of the urine culture lab report as stated in the progress notes, but the lab did not send a copy of the urine culture result. She confirmed the facility did not obtain a copy of the urine culture result for Resident #2 until today ([DATE]). The DON stated the floor nurse, or the unit manager, is responsible for ensuring laboratory results and culture results are received back from the laboratory and reported to the provider. An interview was conducted with Employee A (Licensed Practical Nurse unit manager) on [DATE] at 11:03 AM. She stated it was each nurse's responsibility to ensure they receive pending laboratory results. She stated they document the laboratory tests on a checklist log and check them off when received. She provided the laboratory log for [DATE]. The urinalysis with culture and sensitivity for Resident #2 was listed on [DATE] as obtained but the results received area of the log was blank. She stated it was both the floor nurse and unit manager's responsibility to ensure the results were obtained and reported to the physician. A telephone interview was conducted with the APRN on [DATE] at 12:38 PM. She stated she had no recollection of reviewing the urine culture report dated [DATE] for Resident #2. She stated the resident was declining and at the end of life. She felt for some time hospice should be considered. The resident had an abnormal chest computed tomography scan and the family refused a biopsy. She stated the resident was taking a prophylactic antibiotic for prevention of urinary infections and she would not prescribe additional antibiotics without a culture unless the resident was really symptomatic. She felt the resident's decline could be attributed to a possible lung malignancy. Review of the facility policy for Test Results (Version 1.0 H5MAPL0881 revised [DATE]) revealed the policy stating, The resident's Attending Physician will be notified of the results of diagnostic tests. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record.

Based on interview, record review, and policy review, the facility failed to provide a 30-day notice of discharge for 1 of 4 sampled residents. (Resident #1) The findings include: On 3/30/2023 at approximately 12:30 PM, an interview was conducted with the Director of Social Services. She explained that Resident #1 went home on 3/4/23 for a weekend visit with his family. She said: I was told by the Facility Administrator (FA) that the decision was made for him not to return to the facility. He was discharged to home with his daughter. He has two daughters. They take turns taking care of him. One of his daughters works here. We sent a packet to another facility but he was not accepted. On 3/30/23 at approximately 1:30 PM, an interview was conducted with Resident #1's daughter. She explained that her brother-in-law came to the facility to pick him up to go out on pass on 3/4/23. She said she was told that her father was under investigation. She explained that the FA called Monday 3/6/23. The FA explained that he would be discharged . Resident #1 is now living with her and her sister. On 3/30/23 at approximately 2:30 PM, an interview was conducted with the FA. She explained that Resident #1 left with his family to go on pass on 3/4/23. It had been reported by another resident (Resident #2) that Resident #1 groped her breast. Resident #2, who made the allegations, was competent, credible, and capable of expressing herself. The FA explained that the event had been reported and an investigation was conducted. The FA explained that Resident #1 was ambulatory and capable of getting around the facility easily. Resident #1 has a Brief Interview for Mental Status score (BIMS) of 15, which indicates full mental capabilities were observed. She explained that he has become agitated in the past when on enhanced supervision. The FA explained that Regulation 483.15 C8 contains exceptions to the 30-day requirement. The FA said that she had concerns for the safety of other residents in the facility. She called the family to notify them that arrangements for his discharge were being made. The Director of Social Services was notified. The FA provided a typed statement and a copy of the facility's discharge policy. A record review was conducted. The resident was discharged from the facility on Monday 3/6/23 after being sent home on pass with his family. On 3/30/23 a review of the discharge policy was conducted. The policy stated that a 30-day notice of discharge would be issued. Exception to this rule would be when the health and safety of individuals in the facility would be endangered due to the clinical or behavioral status of the Resident.