**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to obtain Facility Initiated Discharge Physician Orders, follow current Discharge Care Plans, provide written 30 Day Notice of Discharges to resident's/resident's responsible party, document discharge planning and resident specific needs/services, and document sufficient preparation/orientation to residents to ensure safe/orderly transfers/discharges from the facility for 13 of 14 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 14. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger. Findings include: The Facility Resident Midnight Census Report, dated 4/25/25, documents 23 occupied Resident beds in the Facility. The Facility Resident Room Roster, dated 4/29/25, documents 20 Residents residing in the Facility. The Facility Resident Room Roster, dated 5/2/25, documents 17 Residents residing in the Facility. The Facility Action Summary, dated 4/25/25, documents discharges to area Skilled Nursing Facilities for R6 (3/27/25), R7 (4/18/25), R8 (4/18/25), R9 (4/15/25), R10 (4/10/25), R11 (4/10/25), R12 (4/16/25) and R13 (4/9/25). The Facility Discharge Report, dated 4/29/25, documents discharges to area Skilled Nursing Facilities for R2 (4/28/25) and R5 (4/25/25). The Report documents one discharge to a private home for R4 (4/26/25). The Facility Discharge Report, dated 5/2/25, documents discharges to area Skilled Nursing Facilities for R14 (4/28/25). 1) R1's admission Record, dated 4/29/25, documents that R1 admitted to the facility on [DATE]. R1's diagnoses upon admission to the Facility includes Hemiplegia related to a Cerebral Infarction affecting Right Dominant Side, Peripheral Vascular Disease and Bypass Graft of Left Leg, On 4/25/25 at 10:57 am, R1 (Resident Council President) stated, They asked me to leave, and I turned them down. They are asking everyone to leave. R1's current Care Plan does not document discharge planning or Facility planning concerning R1's long term plan to remain in the Facility. R1's Medical Record does not document a discharge meeting, or a request made by R1 to transfer/discharge. 2) R2's admission Record, dated 4/29/25, documents that R2 admitted to the facility on [DATE] and discharged on 4/28/25 at 4:00 pm to nursing home unknown. R2 has no Responsible party documented. R2's diagnoses upon admission to the Facility included Hemiplegia and Hemiparesis following Subarachnoid Hemorrhage affecting Left Dominant side, Dysphagia following Cerebral Infarction and Sacrum Fracture. R2's Physician Order Sheet, dated 4/23/25, documents: to discharge to (local Facility) on 4/28/25; to continue with current medication list and orders; will continue to follow current Physician at this facility. R2's Social Service Nursing Note, dated 4/24/25 at 12:38 pm, documents that R2 has a Power of Attorney for healthcare. The Nursing Note documents that R2 is planning on discharging to another facility/institution for long term placement and that discharge date is set for 4/28/25. R2's Nursing Note, dated 4/24/25 at 12:46 pm, documents, Admissions Coordinator from (Facility being transferred to) contacted Facility and stated they would provide transportation on 4/28/25 at 8:00 am for discharge to their Facility. R2's Nursing Note, dated 4/28/25 at 4:56 pm, documents, (R2) was discharged to (local Facility) and taken with their (Local Facility) transportation van. (R2) is alert and able to make her needs know(n). (R2) took (R2's) medications and (R2's) belongings. (R2's) skin is intact. Report called to (local Facility). R2's current Care Plan documents that R2's wish(es) to discharge to (local Facility), to establish a pre-discharge plan and evaluate progress and revise plan as needed and encourage R2 to discuss concerns and feelings impending discharge. On 4/25/25 at 11:15 am, R2 stated, They said they are doing some remodeling and restructuring or something, so I had to leave. I did not even know anything about it, but they told me I was going to tour some other Facility here in town, I did not have much of a choice. I figured I had better go or they would throw me out on the street, and I did not want to wait until last minute and not be able to find a place to stay. They did not really even give me a choice to stay here. R2's Medical Record does not document services available/unavailable/able to be provided to meet R2's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party or 30-day Notice of Transfer/Discharge. R2's Medical Record does not document a discharge meeting or R2's request for transfer/discharge. 3) R4's admission Record, dated 4/29/25, documents that R4 admitted to the facility on [DATE] and discharged on 4/26/25 at 8:52 am, to a private home with home health services. R4's Responsible party is documented as V8 (R4's Son). R4's diagnoses upon admission to the Facility included Cirrhosis of the Liver, non-Hodgkin lymphoma, Peripheral Autonomic Neuropathy, Spinal Stenosis, Depression, Lymphedema and Delusional Disorders. R4's Social Service Note Nursing Note, dated 4/23/25 at 3:07 pm, documents that R4 is discharging to parents' home and have their own home health services, so will have the services help R4 with any services R4 needs. The Note also documents that R4 left with current orders and medication, follow-up within seven days of discharge, has appointment with primary doctor set up and that V16 (R4's Medical Doctor) is aware of discharge. On 4/25/25 at 10:50 am, V14 (R4's Sister/Responsible Party) was in R4's room packing personal belongings. R4 stated, We got a mess in here, we are packing because I am leaving tomorrow. We got asked to leave. My Sister (V14) and Brother-n-law are moving me to my parents' house. We are not real happy about this. On 4/25/25 at 10:54 am, V14 (R4's Sister) stated, We got asked to leave. We are taking my brother (R4) to my parents' house in Iowa. We are not real happy about all of this, but we had no choice. R4's Medical Record does not document services available/unavailable to be provided to meet R4's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R4's Medical Record does not document a discharge meeting or R4's request for transfer/discharge. 4) R5's admission Record, dated 4/29/25, documents that R5 admitted to the facility on [DATE] and discharged on 4/25/25 at 4:00 pm to an unknown nursing home. (V15) is documented as R5's Responsible party. R5's diagnoses upon admission to the Facility included Cerebral Infarction, Vascular Dementia, Anxiety Disorder, Depression, Diabetes Mellitus and Morbid Obesity. R5's Nursing Note, dated 4/24/25 at 12:16 pm, documents that (R5) is aware and daughter (V15) is aware that (R5) is going to a (local Facility). (V15) is the Power of Attorney (POA). R5's Social Service Nursing Note, dated 4/24/25 at 4:56 pm, documents R5's discharge to a local facility/institution. On 4/25/25 at 11:20 am, R5 (dressed and waiting for transport, with boxes in room) stated, They tell me that I am going to another Facility. I would just as soon stay here, but they did not give me a choice. I was told that I have to go to their sister facility in Aledo, Illinois, that is a lot farther away, but I wanted to go the Facility that my daughter works at. This has been very poor planning. I did not even know anything about this until last night. My friend had to come in and pack me up, so I am all packed up and waiting for them to come get me. I do not know why all of the sudden they just want me to leave. I like my room, I do not have any problems here, they give me anxiety and I am sure that this is going to be the worst trip of my life. They are supposedly supposed to be here any time to get me. This is just a mess, I feel like I got no choice in the matter and was forced out of here, it makes me really sad and angry. Apparently, they are doing some remodel and restructuring or something, I do not really understand. They did not give me any paperwork about my discharge. R5's Nursing Note, dated 4/25/25 at 3:14 pm, documents (local Facility) came to pick up (R5) and (V15) is aware. Resident skin is intact and the area to (R5's) coccyx is intact and Doctor is aware. Treatment in place at this time for preventative. Report has been called to (local Facility). (R5) took medication and belongs (belongings). (R5) is alert and able to make needs known. (R5) uses the wheelchair, both wheelchairs and commode were sent with (R5). R5's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R5. R5's current Care Plan documents that R5 wishes to discharge to a local Facility. R5's Medical Record does not document services available/unavailable/able to be provided to meet R5's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party or 30-day Notice of Transfer/Discharge. R5's Medical Record does not document a discharge meeting or R5's request for transfer/discharge. 5) R6's admission Record, dated 4/25/25, documents that R6 admitted to the facility on [DATE] and discharged on 3/27/25 at 11:40 am, to an unknown nursing home. V7 (R6's Sister) is documented as R6's Power of Attorney. R6's diagnoses upon admission to the Facility included Dementia, Anxiety Disorder, Obsessive Compulsive Disorder, heart Failure, Myocardial Infarction, Mixed Obsessive-Compulsive Disorder, Depression and Diabetes Mellitus. R6's Nursing Note, dated 3/26/25 at 4:10 pm, documents that (R6) to discharge to (sister Facility). (R6) is aware along with Doctor and (V7) has been updated. Will continue with current medication and diet order. Scripts have been updated and sent to Pharmacy. (R6) has no skin issues at this time. (R6) is alert and able to make his needs known. (R6) is able to ambulate without difficulties. (R6) does use (R6's) wheelchair to propel himself throughout the Facility. Medication will be sent with the (R6) and his belongings. R6's Nursing Note, dated 3/27/25 at 9:23 am, documents that (R6) was talked to this morning concerning relocating to (sister Facility). (R6) wants to go. (R6) does not want to stay here. (R6) is alert and able to make his needs know(n). (V7) did state to let (R6) go to (sister Facility) if this is what (R6) wants. Education was provided to (V7) this is his wish at this time. R6's Nursing Note, dated 3/27/25 at 10:33 am, documents that R6 left to another facility (Facility). R6's Nursing Note, dated 3/27/25 at 11:32 am, documents (R6) was picked up and is being transported to (sister Facility). (R6) is in (R6's) wheelchair. (R6's) skin is intact. R6's vital signs were stable and R6 denied pain. (R6's) belongings were sent with the Resident along with medication and narcs (narcotics). Report was called to the Facility and Family is aware. R6's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R6. R6's Medical Record does not document services available/unavailable to be provided to meet R6's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R6's Medical Record does not document a discharge meeting or R6's request for transfer/discharge. On 4/25/25 at 11:36 am, V7 (R6's Sister) stated, My brother (R6) has been at that facility for almost two years. I told them not to discharge my brother, but according to them, they said that my brother (R6) wanted to go, but I do not believe it. So, I finally, just told them to let him discharge. They literally gave me one day's notice. My brother (R6) told me it all started when they wanted to transfer (R6) to their sister facility, but that is over a half hour further away. I wanted a referral to a more local place in Rock Island, but I am not sure why that did not happen. I found all of this out after they made all of the arrangements. Also, apparently (R6's) local State Insurance had lapsed right before (R6) had to transfer, and I did not get any notice of this either, but it was me that had to get the paperwork together real quick for them. Apparently, from what I hear now, they are making it a mental health facility. The Facility did not give me a written Thirty Day Notice before they discharged my brother (R6). 6) R7's admission Record, dated 4/25/25, documents that R7 admitted to the facility on [DATE] and discharged on 4/18/25 at 3:46 pm, to an unknown nursing home. R7's Responsible Party is documented as V9 (R7's Granddaughter). R7's diagnoses upon admission to the Facility included Alzheimer Dementia, Anemia, Osteoporosis, Anxiety Disorder and Scoliosis. R7's Nursing Note, dated 4/18/25 at 1:03 pm, documents that R7 will be discharging to another local Facility today and that R7 and R7's family are aware of orders received. R7's Nursing Note, dated 4/18/25 at 3:09 pm, documents that R7 was discharged to another local Facility and that R7's family is aware, belongings and medications went with. The Nursing Note documents that R7 is confused, and skin is intact. R7's current Care Plan documents that R7 expressed to remain in the Facility for permanent placement; concerns will be addressed in a timely manner; R7 and Responsible Party (V9) will be invited to bring any concerns to the Facility staff; will state comfort with current setting; and Responsible Party (V9) will be contacted with concerns. R7's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R7. R7's Medical Record does not document services available/unavailable to be provided to meet R7's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R7's Medical Record does not document a discharge meeting or R7's request for transfer/discharge. On 4/25/25 at 12:23 pm, V9 (R7's Granddaughter/Responsible Party) stated, My Grandma has Dementia and had been at that Facility for a couple years. My Grandpa (R8) also lived at the Facility with her (R7). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want (R7) to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small-town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and I did not receive any written notice of any kind. 7) R8's admission Record, dated 4/25/25, documents that R8 admitted to the facility on [DATE] and discharged on 4/18/25 at 3:48 pm, to an unknown nursing home. R8's Responsible Party is identified. R8's diagnoses upon admission to the Facility included Alzheimer Dementia, Prostate Cancer, Behavioral Mood Disturbance and Anxiety Disorder. R8's Social Service Note Nursing Note, dated 4/17/25 at 1:17 pm, documents that R8 is discharging to a local Facility on 4/18/25 for long-term placement. R8's Nursing Note, dated 4/17/25 at 3:54 pm, documents that V17 (R8's Power of Attorney/Sister) was contacted regarding a referral to a local Facility for R8 requiring a higher level of care and that V17 agreed to the referral. The Nursing Note documents that R8 will discharge to the local Facility on 4/18/25. The Nursing Note did not document the higher level of care reason or diagnoses for the discharge or other facility referral options available for R8. R8's Nursing Note, dated 4/18/25 at 3:12 pm, documents was discharged to the local Facility; family is aware; medications and belongings were sent; alert with some confusion; skin intact; walks with a walker and does need assistance with activities of daily living (ADL's); and report was called to Facility. R8's current Care Plan documents: R8 desires to remain in the Facility for permanent placement; concerns will be addressed in a timely manner; R8 and Responsible Party (V9) will be invited to bring any concerns to the Facility staff; will state comfort with current setting; and Responsible Party (V17) will be contacted with concerns. R8's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R8. R8's Medical Record does not document services available/unavailable to be provided to meet R8's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R8's Medical Record does not document a discharge meeting or R8's request for transfer/discharge. On 4/25/25 at 12:23 pm, V9 (R8's Granddaughter) stated, My Grandpa has dementia and had been at that Facility for years. My Grandma (R7) also lived at the Facility with him (R8). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want my grandparents to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and we did not receive any written notice of any kind. 8) R9's admission Record, dated 4/25/25, documents that R9 admitted to the facility on [DATE] and discharged on 4/15/25 at 10:43 am to an unknown nursing home. R9's Responsible party was V10 (R9's Mother). R9's diagnoses upon admission to the Facility included Chronic Obstructive Pulmonary Disease, Diabetes, Depression, Anxiety, Schizoaffective Disorder, Insomnia and Bipolar with Manic Severe with Psychotic Features. R9's Nursing Note, dated 4/14/25 at 10:25 am, documents that V10 (R9's Mother) was informed of Resident leaving for a Sister Facility and that everyone is in agreement and (R9) will no(t) be educated on the move until (R9) is ready to be moved related to negative behaviors. R9's Nursing Note, dated 4/14/25 at 3:08 pm, documents that V10 was informed of R9 leaving for a Sister Facility on 4/15/25 at 9:30 am. R9's Social Service Note Nursing Note, dated 4/15/25 at 11:34 am, documents that R9 was discharge to a Sister Facility. V10 helped pack up R9's belongings. R9's medications and orders were sent with transportation. The Nursing Note documents: is alert and able to make needs known; skin is intact; report was called to Sister Facility; belongings went with R9 and V10 took the rest of belongings. R9's current Care Plan documents a desire to remain at current Facility for permanent placement. R9's Physician Order Sheet, dated 4/29/25 does not document a discharge order for R9. R9's Medical Record does not document services available/unavailable to be provided to meet R9's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R9's Medical Record does not document a discharge meeting or R9's request for transfer/discharge. On 4/25/25 at 12:33 pm, V10 (R9's Power of Attorney/Mother) stated, My daughter (R9) has been at this facility for about 14 years and her discharge was not initiated by me, I was not given an option. Someone called me and asked me which date I wanted her to leave, and I told them that I did not know. They went ahead and made arrangements for my daughter (R9) to go to their Sister Facility that is over an hour drive away. It puts a lot of pressure on me to drive that far away. I am [AGE] years old, and I drive a 2008 vehicle that I do not trust on the interstate. My daughter (R9) had her own refrigerator, and I used to come to see her about every day and bring her stuff all the time, like food and personal items, and now I cannot do that at all because it is too far. It has been all messed up since they discharged her. First of all, they did not even transfer any of her medications, so we could not order any for her at the new place, and she takes a lot of medications for her mental issues. It has just been hectic ever since. 9) R10's admission Record, dated 4/25/25, documents that R10 admitted to the facility on [DATE] and discharged on 4/10/25 at 3:55 pm to an unknown Nursing Home. R10's Responsible party was V11 (R10's Son). R10's diagnoses upon admission to the Facility included Encephalopathy, Chronic Kidney Disease Stage Three, Syncope and Collapse, Left Wrist Fracture, Cerebellar Ataxia, Hearing Loss and Dementia. R10's Social Service Note Nursing Note, dated 4/7/25 at 11:34 am, documents that R10 will discharge to another Facility/Institution. R10's Nursing Note, dated 4/7/25 at 12:36 pm, documents that R10 has orders to discharge to another local Nursing Home and that R10 and V11 are aware. R10's Nursing Note, dated 4/10/25 at 3:52 pm, documents: R10 transferred to a local Nursing Home; belongings were transported by V11; report was called; R10 is wheelchair bound; alert and confused (alert X/times 1); skin intact; and V11 is aware of transfer. R10's current Care Plan documents that R10 has expressed a desire to remain at Facility for permanent placement. R10's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R10. R10's Medical Record does not document services available/unavailable to be provided to meet R10's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R10's Medical Record does not document a discharge meeting or R10's request for transfer/discharge. On 4/25/25 at 12:47 pm, V11 (R10's Power of Attorney/Son) stated, About two weeks ago, I received a phone call from the Facility saying they wanted to move a bunch of people out of the Facility. They suggested I move Mom (R10) to one of their other Facility's in another town, but I told them that it was too far, so she went to another one here in town that is closer. My Mom has been in this Facility for two-and a-half years. They gave us little notice and did not really give us an option to stay, they pretty much said that they are going to make it a mental health Facility. So, we had to move her, and after we got her to the new Facility, we had a difficult time getting her medical records from the old place. My Mom is in Hospice care, and she is not doing good at all, and I honestly expect that she dies any day. 10) R11's admission Record, dated 4/25/25, documents that R11 admitted to the facility on [DATE] and discharged on 4/10/25 at 3:55 pm, to an unknown Nursing Home. R11's Responsible party was V12 (R11's Daughter). R11's diagnoses upon admission to the Facility included Heart Failure, Spinal Stenosis, Cataract, Peripheral Autonomic Neuropathy, Chronic Obstructive Pulmonary Disease and Lumbar Vertebrae Fracture. R11's Social Service Note Nursing Note, dated 4/7/25 at 10:57 am, documents that R11 and V12 (R1's Daughter) is aware of R11's discharge to a local area Nursing Home and that orders for discharge were received. R11's Nursing Note, dated 4/10/25 at 3:43 pm, documents that R11 was transported to a local area Nursing Home and report was given. R11's belongings and medication were transported. R11 is alert, able to make needs known, uses a wheelchair to ambulate and skin intact. R11's current Care Plan documents that R11 has expressed a desire to remain at the Facility for permanent placement and that V11 will be contacted for any concerns. R11's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R11. R11's Medical Record does not document services available/unavailable to be provided to meet R11's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R11's Medical Record does not document a discharge meeting or R11's request for transfer/discharge. On 4/25/25 at 1:36 pm, V12 (R11's Power of Attorney/Daughter) stated, My Mom (R11) has been at that Facility since 2019. I got a call on Wednesday (4/9/25) that they were going to discharge my Mom. They suggested that my Mom (R11) could go to another one of their Facilities and I said no, they were too far away. I had to go get her on Thursday (4/10/25) and take her to the new place because they were not going to take her over there. They were very rude about everything and not very helpful. I really did not want Mom moved, but I did not think I had a choice. 11) R12's admission Record, dated 4/25/25, documents that R12 admitted to the facility on [DATE] and discharged on 4/16/25 at 10:00 am, to an unknown Nursing Home. R12's Responsible party was R12. and R12's diagnoses upon admission to the Facility included Cerebral Palsy and Depression. R12's Nursing Note, dated 4/7/25, documents that R12 is aware of discharge to sister Facility. R12's Social Service Note Nursing Note, dated 4/15/25 at 11:16 am, documents that R12 is discharging to the community. R12's Nursing Note, dated 4/16/25 at 10:51 am, documents that R12 was discharged to a sister Facility (approximately 40 miles away). The Note documents that R12 is aware, used wheelchair, skin intact and medications/belongings sent. R12's current Care Plan documents that R12 has expressed a desire to remain at the Facility for permanent placement and to notify Physician of any changes. R12's Medical Record does not document services available/unavailable to be provided to meet R12's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R12's Medical Record does not document a discharge meeting or R12's request for transfer/discharge. 12) R13's admission Record, dated 4/25/25, documents that R13 admitted to the facility on [DATE] and was discharged on 4/9/25 at 10:13 am to an unknown Nursing Home. R13's Responsible party was V8 (R13's Son). R13's diagnoses upon admission to the Facility included Chronic Obstructive Pulmonary Disease, Diabetes, Chronic Kidney Disease Stage Three and Depression. R13's Nursing Note, dated 4/7/25 at 12:03 pm, documents that R13 is discharging to a sister Facility, (V8/Son) is aware and new orders received. R13's Social Service Note Nursing Note, dated 4/7/25 at 3:48 pm, documents that R13 is discharging to another Facility/Institution. R13's current Care Plan documents R13/Responsible Party (V8) are in favor of long-term placement, no discharge/transfer potential at this time. R13's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R13. R13's Medical Record does not document services available/unavailable to be provided to meet R13's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R13's Medical Record does not document a discharge meeting or R13's request for transfer/discharge. On 4/29/25 at 9:06 am, V8 (R13's Power of Attorney/Son) stated, I moved my Dad (R13) there about a year ago for Physical Therapy. The old company got bought out and got new owners, then he (R13) did not get therapy anymore. About a month ago, I got a phone call from them, and they told me that they were transitioning to a different type of building, more for mental health. They told us that if we went to one their own facility's (a town over 30 miles from here) that my Dad could get physical and occupational therapy, because they did not offer therapy there anymore. They did not say anything about a date he was moving or anything. We really did not get an option to stay, I just figured at that time that it would be more beneficial if my Dad could get some therapy. Then out of the blue, I think it was a Thursday (3/27/25), my Dad calls me and tells me that they moved him to the new place. I found out that he had been at the new Facility for two days and I did not even know it. They did not take his recliner with him either, I had to go get it, so Dad sat without his recliner for days until I could get it to him. This new facility he is at is extremely further. Now it takes an hour to get to the new place and it used to only take me fifteen minutes to get to that place. The funny thing is, no one has even called me from the new facility and my Dad still has not even gotten screened for therapy, and he has been there at least three weeks. About a week later, I took Dad his recliner and some diet pop and he also told me at that time that he had not even gotten a shower yet either. I cannot get anyone to call from either place. I did not get a written notice of Dad's discharge or given any other option on where we could go. There were no advocates there to help me, I even mentioned bringing him near me, in Iowa, and no one was real receptive of that either. Also, his brothers and sisters live here in town and now that cannot go see him at the new place, because it is too far for them to drive. 13) R14's admission Record, dated 4/25/25, documents that R14 admitted to the facility on 11/5//24 and was discharged on 4/9/25 at 2:11 pm to an unknown Nursing Home. R14's Responsible party was R14's. R14's diagnoses upon admission to the Facility included Diagnosis: Chronic Obstructive Pulmonary Disease, Right Femur Surgical Amputation, Osteomyelitis, Diabetes, Hemiplegia, Peripheral Vascular Disease and Depression. R14's Social Service Note Nursing Note, dated 4/7/25 at 4:06 pm, documents that R14 is discharging to another Facility/Institution. R14's Nursing Note, dated 4/29/2025 at 11:12 am, documents that orders for discharge were received and family is aware. R14's Nursing Note, dated 4/29/25 at 2:31 pm, documents R14 was picked up by family and is being discharged to a local area Nursing Home. The Nursing Note documents that R14 is alert and is able to make needs known, skin intact, uses a wheelchair, medication/ belonging sent with R14. R14's Social Service Nursing Note, dated 4/29/2025 at 3:18 pm, documents that R14 is discharging to a local area Nursing home on 4/30/25. R14's Parents plan on transporting and will pick. R14's current Care Plan documents an entry on 4/29/25, that R14 wishes to be discharged to home or another facility. R14's Physician Order Sheet, dated 4/29/25, does not document a discharge order for R14. R14's Medical Record does not document services available/unavailable to be provided to meet R14's needs at the Facility, written reason and notification to the Resident/Resident Responsible Party for discharge or 30-day Notice of Transfer/Discharge. R14's Medical Record does not document a discharge meeting or R14's request for transfer/discharge. On 5/2/25 at 9:02 am, V5 (Community Ombudsman) stated, When I was here last week, I notified my boss (V4) that the Facility is trying to discharge everyone, and they are not issuing thirty-day notices to the Residents before they discharge them. The Facility is the one initiating all of the discharges. They are talking to Residents and calling families about dischar[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to notify Resident/Resident's Representatives of transfers/discharges and the reasons for the move in writing at least 30 days prior to transfer discharge, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights for 12 of 14 Residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 18. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger. Findings include: The Facility Action Summary, dated 4/25/25, documents discharges to area Skilled Nursing Facilities for R6 (3/27/25), R7 (4/18/25), R8 (4/18/25), R9 (4/15/25), R10 (4/10/25), R11 (4/10/25), R12 (4/16/25) and R13 (4/9/25). The Facility Discharge Report, dated 4/29/25, documents discharges to area Skilled Nursing Facilities for R2 (4/28/25) and R5 (4/25/25). The Report documents one discharge to a private home for R4 (4/26/25). 1) R2's admission Record, dated 4/29/25, documents that R2 admitted to the facility on [DATE] and discharged on 4/28/25 at 4:00 pm to nursing home unknown. R2's Physician Order Sheet, dated 4/23/25, documents: to discharge to (local Facility) on 4/28/25. On 4/25/25 at 11:15 am, R2 stated, They said they are doing some remodeling and restructuring or something, so I had to leave. I did not even know anything about it, but they told me I was going to tour some other Facility here in town, I did not have much of a choice. I figured I had better go or they would throw me out on the street, and I did not want to wait until last minute and not be able to find a place to stay. They did not really even give me a choice to stay here. I did not receive any paperwork. R2's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge, record the reason for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights. R2's Medical Record does not document a discharge meeting or R2's request for transfer/discharge. 2) R4's admission Record, dated 4/29/25, documents that R4 admitted to the facility on [DATE] and discharged on 4/26/25 at 8:52 am, to a private home with home health services. On 4/25/25 at 10:50 am, R4's stated, We got a mess in here, we are packing because I am leaving tomorrow. We got asked to leave. My Sister (V14) and Brother-n-law are moving me to my parents' house. We are not real happy about this. We did not get any notice or anything in writing. On 4/25/25 at 10:54 am, V14 (R4's Sister) stated, We got asked to leave. We are taking my brother (R4) to my parents' house in Iowa. We are not real happy about all of this, but we had no choice. I did not receive a notice or any type of paperwork in writing. This all just happened in a matter of a few days. R4's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights. R4's Medical Record does not document a discharge meeting or R4's request for transfer/discharge. 3) R5's admission Record, dated 4/29/25, documents that R5 admitted to the facility on [DATE] and discharged on 4/25/25 at 4:00 pm to an unknown nursing home. On 4/25/25 at 11:20 am, R5 (dressed and waiting for transport, with boxes in room) stated, They tell me that I am going to another Facility. I would just as soon stay here, but they did not give me a choice. I was told that I have to go to their sister facility in Aledo, Illinois, that is a lot further away, but I wanted to go the Facility that my daughter works at. This has been very poor planning. I did not even know anything about this until last night. My friend had to come in and pack me up, so I am all packed up and waiting for them to come get me. I do not know why all of the sudden they just want me to leave. I like my room, I do not have any problems here, they give me anxiety and I am sure that this is going to be the worst trip of my life. They are supposedly supposed to be here any time to get me. This is just a mess, I feel like I got no choice in the matter and was forced out of here, it makes me really sad and angry. Apparently, they are doing some remodel and restructuring or something, I do not really understand. They did not give me any type of paperwork about my discharge. R5's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights. R5's Medical Record does not document a discharge meeting or R5's request for transfer/discharge. 4) R6's admission Record, dated 4/25/25, documents that R6 admitted to the facility on [DATE] and discharged on 3/27/25 at 11:40 am, to nursing home unknown. R6's Power of Attorney is identified as V7 (R6's Sister). On 4/25/25 at 11:36 am, V7 (R6's Sister) stated, My brother (R6) has been at that facility for almost two years. I told them not to discharge my brother, but according to them, they said that my brother (R6) wanted to go, but I do not believe it. So, I finally, just told them to let him discharge. They literally gave me one day's notice. My brother (R6) told me it all started when they wanted to transfer (R6) to their sister facility, but that is over a half hour further away. I wanted a referral to a more local place in Rock Island, but I am not sure why that did not happen. I found all of this out after they made all of the arrangements. Also, apparently (R6's) local State Insurance had lapsed right before (R6) had to transfer, and I did not get any notice of this either, but it was me that had to get the paperwork together real quick for them. Apparently, from what I hear now, they are making it a mental health facility. The Facility did not give me a written thirty-day notice or any paperwork when they discharged my brother (R6). R6's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R6's Medical Record does not document a discharge meeting or R6's request for transfer/discharge. 5) R7's admission Record, dated 4/25/25, documents that R7 admitted to the facility on [DATE] and discharged on 4/18/25 at 3:46 pm, to nursing home unknown. R7's Responsible Party is identified as V9 (R7's Granddaughter). On 4/25/25 at 12:23 pm, V9 (R7's Granddaughter/Responsible Party) stated, My Grandma has dementia and had been at that Facility for a couple years. My Grandpa (R8) also lived at the Facility with her (R7). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want (R7) to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small-town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and I did not receive any written notice of any kind for anything to do with Grandma's discharge. R7's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R7's Medical Record does not document a discharge meeting or R7's request for transfer/discharge. 6) R8's admission Record, dated 4/25/25, documents that R8 admitted to the facility on [DATE] and discharged on 4/18/25 at 3:48 pm, to nursing home unknown. V17 (R8's Sister/Responsible Party) is identified as R8's Responsible Party. On 4/25/25 at 12:23 pm, V9 (R8's Granddaughter) stated, My Grandpa has dementia and had been at that Facility for years. My Grandma (R7) also lived at the Facility with him (R8). I got a phone call and was told that they are changing the dynamics of the Facility and offered my grandma and grandpa (R7 and R8) to go all the way to their sister Facility, but that was another 45 minutes away, and that I needed to make a decision by 2:00 pm that same day. I did not want my grandparents to go to that Facility because all of our family is local. It just all around sucked because this is the end of their life and has a small-town feel. It really sucks that they do not help these people with dementia. They literally discharged my Grandparents that same day. We did not even have a meeting or anything before that and we did not receive any written notice of any kind. R8's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R8's Medical Record does not document a discharge meeting or R8's request for transfer/discharge. 7) R9's admission Record, dated 4/25/25, documents that R9 admitted to the facility on [DATE] and discharged on 4/15/25 at 10:43 am to an unknown nursing home. R9's Responsible party is V10 (R9's Mother). On 4/25/25 at 12:33 pm, V10 (R9's Power of Attorney/Mother) stated, My daughter (R9) has been at this facility for about 14 years and her discharge was not initiated by me, I was not given an option. Someone called me and asked me which date I wanted her to leave, and I told them that I did not know. They went ahead and made arrangements for my daughter (R9) to go to their Sister Facility that is over an hour drive away. It puts a lot of pressure on me to drive that far away. I am [AGE] years old, and I drive a 2008 vehicle that I do not trust on the interstate. My daughter (R9) had her own refrigerator, and I used to come to see her about every day and bring her stuff all the time, like food and personal items, and now I cannot do that at all because it is too far. It has been all messed up since they discharged her. First of all, they did not even transfer any of her medications, so we could not order any for her at the new place, and she takes a lot of medications for her mental issues. It has just been hectic ever since. V10 verified that no written notices or any paperwork was received from the Facility. R9's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R9's Medical Record does not document a discharge meeting or R9's request for transfer/discharge. 8) R10's admission Record, dated 4/25/25, documents that R10 admitted to the facility on [DATE] and discharged on 4/10/25 at 3:55 pm to an unknown Nursing Home. R10's Responsible party is V11 (R10's Son). On 4/25/25 at 12:47 pm, V11 (R10's Power of Attorney/Son) stated, About two weeks ago, I received a phone call from the Facility saying they wanted to move a bunch of people out of the Facility. They suggested I move Mom (R10) to one of their other Facility's in another town, but I told them that it was too far, so she went to another one here in town that is closer. My Mom has been in this Facility for two-and a-half years. They gave us little notice and did not really give us an option to stay, they pretty much said that they are going to make it a mental health Facility. So, we had to move her, and after we got her to the new Facility, we had a difficult time getting her medical records from the old place. My Mom is in Hospice care, and she is not doing good at all, and I honestly expect that she dies any day. I did not receive any formal written discharge papers. R10's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/Discharge or provide a statement of the resident's appeal rights. R10's Medical Record does not document a discharge meeting or R10's request for transfer/discharge. 9) R11's admission Record, dated 4/25/25, documents that R11 admitted to the facility on [DATE] and discharged on 4/10/25 at 3:55 pm, to an unknown Nursing Home. R11's Responsible party is V12 (R11's Daughter). On 4/25/25 at 1:36 pm, V12 (R11's Power of Attorney/Daughter) stated, My Mom (R11) has been at that Facility since 2019. I got a call on Wednesday (4/9/25) that they were going to discharge my Mom. They suggested that she could go to another one of their Facilities and I said no, they were too far away. I had to go get her on Thursday (4/10/25) and take her to the new place because they were not going to take her over there. They were very rude about everything and not very helpful. I really did not want Mom moved, but I did not think I had a choice, and they did not provide me with any type of written notices or paperwork. R11's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R11's Medical Record does not document a discharge meeting or R11's request for transfer/discharge. 10) R12's admission Record, dated 4/25/25, documents that R12 admitted to the facility on [DATE] and discharged on 4/16/25 at 10:00 am, to an unknown Nursing Home. R12's Responsible party is R12. R12's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R12's Medical Record does not document a discharge meeting or R12's request for transfer/discharge. 11) R13's admission Record, dated 4/25/25, documents that R13 admitted to the facility on [DATE] and was discharged on 4/9/25 at 10:13 am to an unknown Nursing Home. R13's Responsible party is V8 (R13's Son). On 4/29/25 at 9:06 am, V8 (R13's Power of Attorney/Son) stated, I moved my Dad (R13) there about a year ago for Physical Therapy. The old company got bought out and got new owners, then he (V13) did not get therapy anymore. About a month ago, I got a phone call from them and told me that they were transitioning to a different type of building, more for mental health. They told us that if we went to one their own facility's (a town over 30 miles from here) that my Dad could get physical and occupational therapy, because they did not offer therapy there anymore. They did not say anything about a date he was moving or anything. We really did not get an option to stay, I just figured at that time that it would be more beneficial if my Dad could get some therapy. Then out of the blue, I think it was a Thursday (3/27/25), my Dad calls me and tells me that they moved him to the new place. I found out that he had been at the new Facility for two days and I did not even know it. Now it takes an hour to get to the new place and it used to only take me fifteen minutes to get to that place. The funny thing is, no one has even called me from the new facility and my Dad still has not even gotten screened for therapy, and he has been there at least three weeks. I cannot get anyone to call from either place. I did not get a written notice of Dad's discharge or given any other option on where we could go. There were no advocates there to help me, I even mentioned bringing him near me in Iowa, and no one was real receptive of that either. Also, his brothers and sisters live here in town and now they cannot go see him at the new place, because it is too far for them to drive. We definitely did not receive any notices or paperwork of any kind before this happened. R13's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R13's Medical Record does not document a discharge meeting or R13's request for transfer/discharge. 12) R14's admission Record, dated 4/25/25, documents that R14 admitted to the facility on [DATE] and was discharged on 4/9/25 at 2:11 pm to an unknown Nursing Home. R14's Responsible party is R14. R14's Medical Record does not document notification to the Resident/Resident's Representatives of transfer/discharge and the reason for the move in writing at least 30 days prior to transfer/discharge or provide a statement of the resident's appeal rights. R14's Medical Record does not document a discharge meeting or R14's request for transfer/discharge. On 5/2/25 at 9:02 am, V5 (Community Ombudsman) stated, When I was here last week, I notified my boss (V4) that the Facility is trying to discharge everyone, and they are not issuing thirty-day notices to the Residents before they discharge them. The Facility is the one initiating all of the discharges. They are talking to Residents and calling families about discharging to their own Facilities which are located in Aledo, Illinois or Kewanee, Illinois. They are not really giving them an option of where to go, they are also making promises, like therapy services at their sister Facilities and not doing therapy and making good on the promises. I am also aware that they are not going through the right discharge process. On 4/25/25, at 9:55 am, V4 (Ombudsman) stated, (V5/Community Ombudsman) notified me that when (V5) was in the building last week, (V5) was told by multiple Residents that the Facility was discharging everyone and moving people out. No one is getting Statement of Appeal Rights or Thirty Day notices or discharge meetings. They are not getting anything related to these discharges. They were told that they needed to move due to Facility renovations and also that it was getting turned into a mental health facility. Some of these Residents have been at that Facility for years, I am not sure why all of the sudden they need to be discharged , now they are displaced. This is causing families to have to travel further and not being able to visit as often. I have also heard that they are moving them to some of their own facilities that are further away and not giving them Facility options of where to go. This Facility should also be offering all the services that fall under their skilled nursing facility regulations and licensure, but they have not had therapy available for Residents and the staffing has really decreased. (V5) and myself are trying to track all of these discharges at the other Facilities. I have concerns about the Facility going through the right steps on these discharges and the Facility never notified us of all of these discharges either. On 4/29/25 at 9:55 am, V13 (Corporate Social Service Director) stated, This Facility does not currently have a Social Service Director, so I have been coming in and helping out. (V2/Director of Nursing) and I have been reaching out to Residents and making phone calls to family's about moving to our sister Facilities, because we are restructuring to become a mental health facility. I was not aware that we needed to issue Thirty Day Notices or Statement of Appeal Rights. On 4/25/25 at 10:13 am, V3 (Regional Director of Operations) stated, We are not trying to get skilled therapy services because we have not had any skilled therapy for the last few months. We are not doing any renovations that I know of, and I do not know of any work orders or bids for renovations either. We were directed to make phone calls to family members and talk to Residents about transferring to our sister facilities. We plan on making this a mental health and behavioral facility and planned on keeping the same licensure. We did not give thirty-day notices to any of the Residents that discharged . I cannot find documentation from the Physician regarding the Resident needs that could not be met and the reason for discharge, Statement of Appeal Rights or Thirty Day notices for any of these discharges. There are no plans for construction at this Facility. On 4/25/29 at 9:00 am, V2 (Director of Nursing/DON) stated, We are trying to get this to a mental health building. We were directed by Corporate to discharge all of our residents so we could do construction remodeling and restructuring of the Facility to a mental health facility. Corporate is making all of the Facilities that are named 'Avenues' Facility's into their mental health and behavioral facilities. We gave all of the Residents the option to go to our sister facilities, some went to our Facilities, and some wanted to go to other facilities here in town. I do not see in any documentation, and I am not aware that we held actual discharge planning meetings, other than placing a phone call asking for options of what facility they wanted discharged to. I gave you all of the documentation from the Resident's medical records that I have. I do not see that all of the Residents had Physician Discharge Orders, Thirty Day Notices or any documentation for reasons for discharge either. On 4/25/25 at 9:20 am, V1 (Administrator) stated, I was directed to initiate discharges so that we could restructure this facility into a mental and behavioral health facility. At first, we just called all of the families and gave the option to transfer to one of our sister facilities, but some have chosen to go to other facilities closer here in town. We have not been taking any admissions for a few months either. I cannot find any documentation for remodel plans, bids or work orders. I do not think that we have any Thirty Day Discharge Notices or anything other documentation to provide on any of the Residents that have been discharged . On 5/2/25 at 10:28 am, V16 (Medical Director) stated, I was not aware that the Facility is discharging all of these Residents. They have not given me any notice. I have not documented any discharge planning notes or discharge orders for any of the Residents either. No one has discussed this process of this becoming a mental health facility with me. Sometimes they send me just a piece of paper about something, but I never even received a paper about this either. The Facility Assessment Tool, dated 11/2024, documents: 63 licensed beds, currently 30 long stay Residents, very important to have family/friend involved in care discussion for all Residents; support emotional and mental health well-being and offer and assist Resident/Family to be involved in person-centered care planning and advance care planning; educate staff on Resident Rights and facility responsibility to properly care for its Residents; person centered care should include care planning, education of Resident and family representative about treatments and treatment preferences and advance care planning; Resident assessment; specialized care; and consider and plan for how to get input and participation from Residents and their representative/family members throughout the assessment process; getting feedback from the local long-term care ombudsman program and involving Residents and representatives. The Facility Notice of Transfer and Discharge Policy, revised 10/2022, documents: to notify the Resident and the Resident's Representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons for the transfer or discharge in the Resident's medical record; the transfer or discharge is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility; Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility; the safety of the individuals in the Facility is endangered due to clinical or behavioral status; health of the individuals would otherwise be endangered or the Resident has failed, after reasonable and appropriate notice, to pay for a stay at the Facility; when the Facility transfers or discharges a Resident under any of the circumstances (specified in reasons as stated above), the Facility must ensure that the transfer or discharge is documented in the Resident's medical record including reason for the transfer, specific Resident needs that cannot be met, facility attempts to meet the Resident needs and the services available at the receiving Facility to meet the needs; and documentation must be made by the Resident's Physician when the transfer or discharge is necessary; except otherwise specified, the notice of transfer or discharge will be made at least 30 days before the Resident is transferred or discharged ; discharge from the Facility will include review of all necessary items to maintain the individuals highest practicable well-being including medical equipment, medications, appointments and treatments; and in the case of a Facility closure, the Administrator must provide written notification prior to the impending closure to the State Agency, Office of State Long Term Care Ombudsman, Residents at Facility and Resident Representatives, as well as the plan for the transfer and adequate relocation of the Residents. The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: rights to make own choices, must be treated with dignity and respect and must care for in a manner that promotes quality of life; Facility must provide services to keep physical and mental health, at their highest practical levels; may participate in developing a person-centered care plan which states the services the Facility will provide and everything you are expected to do and the Facility must make reasonable arrangements to meet your needs and choices; should receive the services and/or items included in the plan of care; your discharge plan and steps to achieve the goals included in your care plan; have the right to keep living in your facility; must be given written notice if your facility wants you to move from the facility and the reasons for asking you to leave the facility; the notice must tell you why your facility wants you to move, tell you how to appeal the decision; provide a stamped and addressed envelope for you to mail your appeal; and be received 30 days prior to the day they want you to move from a Medicare or Medicaid Facility. The Facility admission Packet, undated, documents: the Facility shall offer nursing care, activities, restorative and rehabilitative services, psychosocial care as identified in the Resident's Plan of Care to the extent required by the Facility Standards and in accordance with the policies of the Facility; and the Termination by Facility Involuntary Transfer or Discharge states the Facility may transfer or discharge a Resident for one more of the following reasons at any time by giving 30 days written notice to the Resident, Representative/Responsible Party as required by state law and regulations (medical reasons, health has improved such that no longer requires services, physical safety for Residents, late payment/non-payment, Facility ceases to operate or otherwise permitted by law).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of a diabetic resident receiving a nutritionally- inadequate clear liquid diet tray for most meals or not eating at all during the span of five days, while continuing to receive the ordered oral and injectable diabetic medications. This failure resulted in R1 being hospitalized for Hypoglycemia and Altered Mental status. FINDINGS INCLUDE: R1's facility Profile Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. R1's Medication Administration Sheet, dated June 2024 includes the following medications: Jardiance (Sodium- Glucose Co- Transporter 2 Inhibitor) 25 MG (Milligrams) one tablet daily at Noon; Tresiba (Long- Acting Human Insulin) 48 Units subcutaneous daily at Noon; Metformin (Antihyperglycemic) 500 MG one tablet twice daily; Novolin R Insulin 4 Units at 7:30 A.M. and 7 Units with Lunch and Dinner. This same form documents from the period of June 10 through June 15, 2024, staff continued to administer all scheduled doses of Jardiance, Tresiba, Metformin, and the Noon dose of Novolin R Insulin and the 5:00 P.M. dose of Novolin R Insulin on June 13, 14, 15, 2024 even though R1 either refused most meals or only drank liquids. R1's current Care Plan, dated 7/18/23 documents, (R1) has a long history of obesity. (R1) consumes more than 75% of meals. (R1) is able to feed himself after with tray set up by staff. (R1) is alert and able to make his needs known. Provide diet as ordered. A review of R1's medical record, including physician orders documents that R1's physician was notified on 6/12/24 of R1's sore throat and productive cough. No documentation that R1's physician was notified of R1's refusal to eat or facility staff only providing liquids, when R1 refused to get out of bed, for the five days preceding R1's hospitalization for hypoglycemia, is available. R1's Ambulance Sheet, dated 6/16/24 at 6:36 A.M. documents, Dispatched for complaints of a sick person at (facility). Upon arrival, (R1) was in bed. (R1) was very confused. Once (R1) was in the back of the ambulance, we evaluated (R1's) blood sugar. (R1) was hypoglycemic at 42 (normal range 70-100). R1's Hospital Discharge summary, dated [DATE] documents, (R1) admitted to hospital from (facility) with Altered Mental Status and Hypoglycemia from 6/16/24 through 6/21/24. History of Present Illness: (R1) presents with altered mental status. (R1) is coming from (facility). (R1) is able to remember this morning, including nursing staff coming into his room but notes he was unable to understand what they were saying. (R1) has had a cold for the past 2 weeks and has been given Robitussin. (R1) states he did not eat breakfast or dinner yesterday. (R1) last had his long-acting insulin at 0800 yesterday and short acting insulin at 1700 yesterday. Differential Diagnosis: General Hypoglycemia. Rationale: Last dose of insulin yesterday evening. Last dose of oral Jardiance yesterday morning. Missed breakfast and dinner last night but still given his dm (diabetes mellitus) type 2 medications. With a half an amp (ampule) of dextrose given in the emergency room, sugars improved to 70's and confusion improved. (R1) denies any starvation or new diet but missed meals while given his medications, dangerous practice. Notes: (R1) is agreeable to admission if accepted, at least observation status to the medical service since (R1) hypoglycemic from recently not given his full meals at (facility), but still given his diabetic insulin including oral Jardiance, regular insulin and ultralong acting insulin. On 7/5/24 at 2:09 P.M., V5/Registered Nurse stated, Residents are not supposed to eat in their rooms, but (R2) is allowed to. I'm not sure why (R2) can. (R1) had been sick for about a week with a head cold. (R1) wasn't eating much. (R1) requested to eat in bed. (R1) can have a sick tray, if (R1) is in bed. A sick tray is only fluids. No, I didn't call his doctor (V11/Medical Doctor) about (R1) not eating. At that time, V5/RN verified she worked the evening (2 PM-10 PM) of June 13, 14 15 (2024). R5/RN also confirmed she administered R1's scheduled dose of Novolin R Insulin on the evening (5 PM) of 6/15/24, even though R1 did not eat breakfast or supper that day. On 7/6/24 at 6:29 P.M., (V11/R1's Medical Doctor) stated, I wasn't notified of (R1) missing meals or only receiving a liquid diet for the days preceding his hospitalization (for hypoglycemia). If I had been notified, I would have changed (R1's) plan of treatment. (R1) could have avoided a hospitalization.