**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R37 On 6/30/25 at 10:15 AM, R37 was observed lying in bed. R37 reported he was not feeling well at that moment and was going to the hospital. When queried about the care in the facility, R37 reported he wore a Life Vest (a wearable cardioverter defibrillator vest that continuously monitors for life-threatening irregular heart rhythms and automatically delivers shock treatment to save a person's life, if needed). R37 reported the vest was not removed because he was to wear it at all times. R37 reported the vest did not fit properly and was very tight which caused a big wound on the trunk of his body where the vest made contact with his skin. R37 reported the facility ordered a new vest, but he never received it. R37 reported the wound was painful and uncomfortable. An observation of the wound to R37's torso was not conducted as R37 left for the hospital shortly after the above interview and did not return prior to the end of the survey. A review of R37's clinical record revealed R37 was admitted into the facility on 6/10/25 with diagnoses that included: ischemic cardiomyopathy (damaged heart muscles that cannot pump blood properly). A review of a Minimum Data Set (MDS) assessment revealed R37 had intact cognition and no unhealed pressure ulcers or other skin impairments. A review of a Nursing Evaluation completed for R37 on admission on [DATE] revealed no documentation of skin impairment to R37's trunk/torso. A review of R37's Physician's Orders revealed an order for weekly skin check every Tuesday with a start date of 6/17/25. An order dated 6/12/25 revealed, Monitor every shift. Patient is to wear LifeVest at all times EXCEPT when showering/vigorous cardiac rehab . A review of a Skin Observation assessment dated [DATE] revealed no skin impairment to R37's trunk/torso was identified. A review of R37's progress notes revealed the following: An IDT (Interdisciplinary Team) Note dated 6/11/25 documented, .Skin rash under breast present upon admission. It should be noted that a skin rash under R37's breast was not documented on the admission Nursing Evaluation or Skin Observation form completed on 6/10/25. Further review of R37's Physician's Orders revealed no treatment orders to address the rash mentioned in that note. Further review of R37's clinical record revealed no further documented assessment of the rash, including the size, appearance, and where it was located (under left or right breast). There was no mention of R37's vest being too tight, as reported by R37. A Physician/PA (Physician Assistant)/NP (Nurse Practitioner) - Progress Note dated 6/11/25 revealed no documentation of any skin impairments. A Skin/Wound Note dated 6/18/25 documented, During shower this am an abrasion was observed under left abdominal fold r/t (related to) life vest. Skin also red moist and has mild order <sic> (odor). After shower area cleansed. Antifungal powder and camalseptine <sic> (an ointment used as a moisture barrier to calm skin irritation) applied. Treatment in place. All necessary parties notified. Further review of R37's Physician's Orders revealed an order dated 6/18/25 for Wound Treatment: Left Abdominal Fold Abrasion: 1. Cleanse area with NS (normal saline) 2. Pat Dry Apply Camalseptine <sic> and Antifungal powder and ABD (abdominal pad) for cushion .every day shift for Wound Care . A review of a Physician/PA/NP Progress Note dated 6/18/25 did not document any skin abnormalities or that R37's life vest did not fit properly. A review of a Weight Change Note dated 6/19/25 revealed R37 gained 4.5 pounds since admission nine days prior. It was noted R37 took a diuretic for edema and weight fluctuations were expected. A review of a consultation completed by the contracted wound care provider dated 6/20/25 revealed, .Wound Assessment(s) .Wound #1 Abdomen - LUQ is an acute Partial Thickness Abrasion .Initial wound encounter measurements are 1.5cm length x 13cm width with no measurable depth .There is a Scant amount of sero-sanguineous drainage (a combination of clear fluid and blood) noted .Wound bed has 100% pink, granulation, 20% slough (non-viable yellow, tan, gray, green or brown tissue) .Additional Orders .ABD DIRECT, OFFLOAD AREA NO ADHESIVE .Avoid direct pressure to wound site .OFFLOAD VEST OFF SITE . It should be noted that according to the State Operations Manual (Rev 229; Issued 4/25/25), if slough is present but does not obscure the depth of tissue loss, it is considered Full-thickness Skin loss and a Stage 3 Pressure Ulcer related to a medical device. A review of a Wound Assessment Details Report completed by Licensed Practical Nurse (LPN) 'O' on 6/27/25 revealed documentation that R37's wound was a Stage 1 facility acquired pressure ulcer (Intact skin with a localized area of non-blanchable erythema) that measured 13cm x 0.5 cm. The photo included on the assessment showed a linear wound with areas of full-thickness tissue loss, slough and scattered black, scab-like areas. A review of a consultation completed by the contracted wound care provider dated 6/27/25 revealed, Wound #1 Abdomen - LUQ is an acute Partial Thickness Abrasion .measurements are 0.5cm length x 13cm width x 0.1 cm depth .Wound bed is 90%, pink, granulation, 10% slough; no eschar . It should be noted in the photo taken on 6/27/25, there were scattered black, scab-like areas. A review of a IDT Note dated 6/25/25 revealed, .Life vest in place, (company name) contacted for new vest . On 7/2/25 at approximately 8:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried if the facility had a Wound Care Coordinator, the ADON reported there was a nurse who rounded with the contracted wound provider once a week and the Director of Nursing (DON) was ultimately the person who oversaw wounds in the facility. On 7/2/25 at 11:53 AM, an interview was conducted with the DON. When queried about how R37 got the wound to his LUQ, the DON said it was from rubbing from the life vest. When queried about how often R37's skin was monitored due to having a medical device (life vest) that was reportedly too tight according to R37, the DON reported at least weekly, but with the vest they should be checking every shift, if not more. At that time, the following was requested from the DON: Interventions in place upon R37's admission into the facility, interventions implemented upon identification of skin breakdown to prevent further breakdown or worsening of the existing wound, and when the new life vest was ordered. The DON said she would look into it. On 7/2/25 at 2:00 PM, a follow up interview was conducted with the DON. The DON reported R37's skin was not checked more frequently because the vest was only to be removed for showers. The DON reported due to the life vest, they were unable to put additional protective interventions in place. At that time, any Wound Assessment Detail Reports conducted prior to 6/27/25 were requested. On 7/2/25 at approximately 2:45 PM, the ADON reported R37 was admitted with some skin impairment to his LUQ. At that time, any documentation of the skin impairment on admission and any physician's orders to treat the area at that time were requested. No additional information was provided prior to the end of the survey. The ADON further reported R37 was fitted for the life vest at the hospital and could only be fit every three months per the life vest company. At that time, it was requested a second time to provide the date the life vest company was contacted to enquire about a better fitting vest. No additional information was provided prior to the end of the survey. The ADON was asked to provide the hospital discharge records, as they were not accessible in the medical record. The records were not provided prior to the end of the survey. A review of R37's care plans did not include any care plans related to R37's medical device related wound to the LUQ and did not include a care plan related to checking R37's skin underneath the left vest. A review of a facility policy titled, Prevention of Pressure Ulcers/Injuries revised 1/2019 read in part, .Risk Assessment .Areas of impaired circulation due to pressure fro positioning of medical devices .CNA's (Certified Nursing Assistants) will inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living) .General Preventive Measures: 6. Routinely screen and document the condition of the resident's skin for any signs and symptoms of irritation or breakdown. 7. Immediately report any signs of a developing pressure ulcer to the supervisor. 8. The care process should include efforts to stabilize, reduce or remove underlying risk factors .Risk Factor - Friction and Shear .Monitor the placement of splints and casts to assure they are not placing friction on the resident's skin . Based on observation, interview and record review, the facility failed to document accurate skin assessments, ensure timely identification of pressure ulcers, and implement effective interventions to prevent the development and worsening of a pressure ulcer, for two (R68 and R37) of two residents reviewed for pressure ulcers resulting in R68 acquiring multiple pressure ulcers first identified as Unstageable (obscured full-thickness skin and tissue loss) and/or Stage 3 (full-thickness skin loss) pressure ulcers and R37 acquiring a medical-device related pressure injury with full-thickness skin loss. Findings include: R68 On 6/30/25 at 10:30 AM, R68 was observed lying in bed. R68 was asked if he had any wounds or sores on his body. R68 explained he had wounds, some he had when he was admitted and some he acquired at the facility. R68 was asked if he could turn himself. R68 explained he could not turn himself, staff had to turn him. Review of the clinical record revealed R68 was admitted into the facility on 1/27/25 and readmitted [DATE] with diagnoses that included: quadriplegia, injury of cervical spinal cord and major depressive disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R68 was cognitively intact. Review of R68's skin impairment care plan revealed interventions that read in part, .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration (excessive moisture exposure) etc. to MD (medical doctor). Date Initiated: 02/27/2025 . Monitor skin when providing cares [sic], notify nurse of any changes in skin appearance Date Initiated: 01/27/2025 . Review of R68's wound notes from a consultant Wound Care Provider revealed: 2/14/25 .Wound #3 Right Elbow is an acute Stage 3 Pressure Injury Pressure Ulcer . Initial wound encounter measurements are 2.4cm (centimeters) length x 1.2cm width .There is a Scant amount of sero-sanguineous (blood serum and red blood cells) drainage . Wound bed has 70%, pink, granulation (new connective tissue formed during the healing process), 30% eschar (dead or devitalized tissue, and may appear scab-like) . General Notes: Patient has a history of Stage 3 on elbow based on previous records at different facility . Wound #4 Left Scapula is an acute Stage 3 Pressure Injury Pressure Ulcer . Initial wound encounter measurements are 1.4cm length x 4cm width . 20% slough (non-viable yellow, tan, gray, green or brown tissue) . General Notes: Patient has a history of a stage 3 ulcer on L (left) scapula based on previous records . 2/28/25 .Wound #5 Right Ischial (lower part of the buttocks) is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer . Initial wound encounter measurements are 3.4cm length x 2cm width . There is a Scant amount of sero-sanguineous drainage . 100% slough . 4/4/25 .Wound #7 Left Ischial is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 03/30/25 . Initial wound encounter measurements are 3cm length x 1.8cm width . There is a Scant amount of sero-sanguineous drainage . Wound bed has 40%, pink, granulation, 60% eschar . Review of R68's progress notes revealed no documentation of skin impairment prior to the Consultant's wound notes on 2/14/25, 2/28/25 and 4/4/25. Including between 3/30/25 and 4/4/25. Review of R68's Skin Observation documentation revealed no identification of a new skin impairment. On 7/2/25 at 10:09 AM, the Director of Nursing (DON) was interviewed and asked how often skin checks should be completed. The DON explained the Skin Observation should be done weekly. The DON was asked why of the 22 weeks R68 had been at the facility, only nine Skin Observation's had been completed. The DON offered no explanation. The DON was also informed of the nine Skin Observations completed, none had identified any new skin impairment. The DON made no reply. The DON was asked about R68's wounds being identified when they were at Unstageable or Stage 3. The DON explained Wounds #3 and #4 were called Stage 3 because they had been at a Stage 3 prior and had reopened. The DON was informed the Consultant had documented that fact, however was asked why Wound #3 was documented as having granulation tissue and was 30% eschar and Wound #4 had 20% slough, which indicated both wounds had been present for a while. The DON offered no explanation. The DON was asked about Wound #5 that was first documented by the Consultant as an Unstageable with 100% slough. The DON offered no explanation. The DON was asked about Wound #7 in which the Consultant had documented was acquired on 3/30/25 but there was no documentation found in R68's record. The DON offered no explanation. The DON was asked if there were pictures of R68's wounds prior to the most recent Consultant's visit. The DON had the ability to access prior pictures and showed the first picture of R68's Wound #7 taken on 4/4/25 which appeared to be almost completely covered in black eschar. The DON was asked if the pressure ulcer in the picture should have been identified and documented before it looked like the image in the picture. The DON agreed there should have been identification before the wound was at that extent. When asked if R68 required total assistance of staff for care, the DON agreed. The DON was asked if staff were changing, bathing and turning R68 should the wounds have been identified and documented on before they were Unstageable and/or Stage 3. The DON acknowledged the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00147691, MI00147358 Based on observation, interviews and record review facility failed implement an effective discharge planning process for two (R901 and R902) of two residents reviewed for transfer/discharge, resulting in psychosocial harm using the reasonable person concept for R901 who has aphasia (difficulty communicating due to damage in the brain), a language barrier, and severe cognitive impairment, was discharged to another facility, farther away from family, without approval from the resident's representative and without notification to the other facility; and R902 feeling frustrated and dissatisfied with their living situation. Findings include: R901 A complaint received from another State Agency revealed the following: (R901's name omitted) family received a call from staff notifying them that (R901's name omitted) would be transferred to (facility name omitted). The staff stated (R901's name omitted) was being transferred because he wanders into other residents' room and the residents hit him. The staff stated they could not look for him when he wanders and unable to care for him anymore. At 2:30 PM, (R901's was transferred to (facility name omitted). A review of R901's Electronic Medical Record (EMR revealed R901 was admitted to the facility on [DATE] after a hospital stay. R901's admitting diagnoses included aphasia, dementia, anxiety disorder, nutritional deficiency, and chronic obstructive pulmonary disease (COPD). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that R901's primary language was not English and they had severe cognitive impairment. R901 had limited ability to communicate due to their diagnosis of aphasia, cognitive impairment and language barrier. R901's spouse was appointed as their Durable Power of Attorney (DPOA) to make decisions on their behalf. During initial and follow-up observations completed on 12/10/24 at approximately 9:45 AM, 10:15 AM and 1:30 PM on the 2nd floor, the surveyor observed Velcro stop signs in doorways of three residents' rooms. An unknown resident was observed walking down the hall and attempted to enter other residents' rooms during those observations. During the observation at 1:30 PM, the resident was observed with unintelligible speech. Staff redirected the resident. When queried about the stop signs on the doors, Certified Nursing Assistant (CNA) A reported they had the signs on the rooms doorways of alert residents to redirect this resident who tends to wander into other resident rooms. Further review of of R901's EMR revealed a progress note titled transfer to hospital or other facility dated 10/3/24 read in part Arabic speaking gentleman with confusion, dementia, heart disease .needs more appropriate placement. Reason for transfer: Needs a more appropriate environment. Usual mental status: alert, disoriented, cannot follow commands. Documents sent: A face sheet was sent with the patient. Medication sheet was sent with the patient and current labs were sent with the patient. A nursing note dated 10/2/24 titled recapitulation of stay read under comprehensive care plan goals, smaller facility or lock down unit needed .spouse is very supportive. A social service progress note dated 10/2/24 at 14:18 read in part, (name omitted) the marketing liaison was here to see and evaluate resident for admission to community. Resident was accepted in both locations but will prefer the (location name omitted - where R901 was discharged to) .would like to receive the resident tomorrow at 11 AM . It must be noted that the location was the preference of the liaison. Further review of R901's EMR revealed social work progress notes dated 10/2/24, that revealed that referrals were sent to these facilities by the facility social worker. Social service progress note dated 10/2/24 at 12:01 read in part, Social worker called and spoke with resident spouse (name omitted). Writer informed his wife that I will be sending referral to (facility names omitted) for more appropriate placement. She responded his confused. Spouse states will be in today to visit. An interdisciplinary (IDT) team note dated 10/2/24 read, IDT discussed the resident for wandering, confusion, and eating food off other resident trays spouse visits often. SW (Social work) is attempting to find more appropriate placement for his cognition. Labs completed on 10/1/24 with nothing remarkable except valproic acid level was low . (name omitted) NP (nurse practitioner) texted . Further review of the records did not reveal that the facility provided any opportunity and or time to discuss the discharge plans with the R901's representative and asked for their input with the plan, location of the facility, how it would be a more appropriate set up for R901's care needs etc. by the facility's social worker and or the interdisciplinary team. There was no evidence that facility had involved the R901's representative/family to develop a resident specific discharge plan to address their care needs before R901 was discharged from the facility to a new facility that was located farther away from the family. A request was sent via e-mail to facility Administrator and Director of Nursing (DON) on 12/10/24 at 2:06 PM to provide any incidents/accidents reports and investigations completed for R901 during their stay at the facility. Facility reported R901 did not have any incidents/accident reports. Further review of R901's EMR revealed a form titled My Transition Home initiated on 10/2/24 at 3:49 PM with a locked date of 10/3/24 at 9:01 AM was not signed by resident/representative. The form read phone (spouse name omitted) -unable to come. The form also read that personal belongings were sent with the resident and it was later confirmed that R901 did not have any personal belongings when they arrived at the facility on 10/3/24. An initial interview was completed with R901's representative (spouse) and R901's daughter on 12/10/24 at approximately 11:35 AM. During the interview with resident representative R901's daughter was also present. R901's spouse reported they were at a hospital receiving care and their daughter was aware of what had happened and they were very involved in R901's care. R901's spouse reported that they were very upset about the discharge. They reported that they were notified by the facility social worker that they were looking for an appropriate placement the day before. They did not know they were transferring their spouse to another facility that was located about an hour away from where they lived. R901's daughter reported that their mother visited R901 almost every day of the week and they also called to check during the day. On 10/3/24, the day of discharge from the facility, R901's representative had called in the morning to check and they were notified by a staff member that R901 was still sleeping and they did not need to come in. Later that day, at approximately 10:30 AM, R901's spouse received a call from the facility social services director (SW) B about R901's transfer to another facility. R901's spouse had requested SW B' to call their daughter. R901's daughter reported that they had received a call from SW B on 10/3/24 at 10:56 AM that they were transferring R901 to the current location. R901's daughter had notified that they were unaware of this facility location and they did not want to approve the transfer to this location. They had notified SW B that this facility was located farther away from where their mother lived and did not want to transfer to this location. They added that they had notified R901's spouse/representative and family was open to look for a facility that was closer to where the spouse resided, as they visited R901 regularly. R901's daughter stated, he may not know us but he needs us. R901's daughter added that during the conversation with SW B they were notified that R901 needed more supervision and they did not have the staff to monitor. R901's daughter reported that they thought R901 stayed at the facility after their conversation. Later that day at 3:14 PM. R901's family received a call from the Social Worker from the facility R901 was transferred to (SW C) to notify them that R901 was at their facility. SW C told the family they were unaware R901 was being transferred to their location, R901 did not arrive with any personal belongings, and R901 was not able to provide any information. R901's daughter reported they attempted to call SW B multiple times on 10/3/24 after the transfer and they were unable to reach her. R901's daughter reported that their mother and brother went to the facility a few days after discharge and picked up R901's personal belongings. It must be noted that based on information received from transportation provider R901 was dropped off at the current facility at approximately 12:45 PM. A follow up interview was completed with R901's daughter on 12/10/24 at approximately 5:35 PM. They confirmed that their mother/R901's representative did not have a meeting with the staff at the facility or administration regarding any discharge planning related to their care needs for their father. They stated that it was done behind our back and their mother/R901's representative was very upset. An interview was conducted with SW B on 12/10/24 at approximately 12:40 PM. They were queried about the discharge planning process. They reported that the discharge planning process started on day one after a resident was admitted to the facility and followed up based on the resident's functional progress, care needs and wishes of the resident/resident representative. They were queried about R901's discharge to another facility and if their discharge plan was communicated with the resident representative. SW B reviewed the EMR and confirmed that R901 needed long term care. They reported that R901 needed 1:1, was restless, high risk for falls and needed more supervision. They added that R901 had a language barrier. They confirmed they had residents who had similar needs at the facility. When queried about other interventions that were tried prior to R901's discharge from the facility, no further explanation was provided. When queried if they met with their IDT and R901's representative/family to discuss R901's care needs, provided options/plan and involved them in planning prior to the transfer on 10/3/24 they stated no. They added that they would arrange for IDT to meet with the family if they had requested for a meeting. When queried about the concerns expressed by the representative about the location of the current facility and their preferences, SW 'B' reported they were not aware and added that if a resident or resident representative did not agree with the plan they would not discharge the resident and did not provide any further explanation. SW 'B' explained they might discharge residents / petition them out to the hospital if their behavior posed a threat to themselves or other residents or staff. They added it would have been documented in their progress notes. An interview with the Unit Manager (UM) D was completed on 12/10/24 at approximately 2:40 PM. During the interview they were queried about R901 and why they discharged to another facility. UM D reported that R901 had dementia, they wandered into other resident rooms, and they moved them into a different room/unit a few days after they were admitted . They added R901 took food off plates and needed close supervision; had their sleep cycles altered, usually slept during the day; and needed smaller facility. They added they did not have any other concerns, R901's family was very supportive; and R901's spouse visited them almost every day. They were queried if they had the resident/resident representative sign their discharge summaries after staff members reviewed and they added that it was verbal and they did not sign. A follow-up interview was conducted with UM D (who had also completed the discharge summary) on 12/11/24 at approximately 12 PM. During the interview they were queried if they spoke with R901's family member and they reported that they do not recall speaking with R901's resident representative on the day of discharge. They added that the social worker followed up. UM D was queried if they or their charge nurse called the facility R901 was transferred to on the day of discharge to provide information on R901 and they stated that they did not call. If their nurse did it should be on their progress note. They added that possibly their DON might have called the other facility. An interview with SW C was conducted on 12/11/24 at approximately 10:50 AM. During the interview they were queried about the R901 and their day of admission to their facility. SW C reported that the facility staff were unaware they R901 was being transferred to be admitted to their facility. They added that R901 was dropped off at their facility lobby and staff did not who R901 was and why they were there. R901 was not able to communicate and they were not able to provide any information. R901 attempted to walk and they were trying to keep him safe while looking for additional information. R901 did not have any of their medications or personal belongings with them. After some time, they were able to locate the face sheet and they had contacted the family and eventually they came in. An interview with Licensed Practical Nurse (LPN) E was completed on 12/11/24 at approximately 11 AM. LPN E worked at the facility where R901 was transferred to and they were the nurse on the floor on 10/3/24 (when R901 was admitted to the facility). They added that they worked on the 2nd floor and they were not expecting R901. R901 was transferred to their floor closer the afternoon shift and they were trying to help the other nurse. R901 did not have any information and they were dropped off downstairs. They were not able to obtain any information from R901. A follow-up interview was conducted with SW B on 12/11/24 at approximately 11:15 AM. During the interview they were queried if they had called and spoke with any staff member at the facility where R901 was transferred prior to transfer. SW B reported that they spoke with a liaison from the organization during the onsite visit and did not speak with any staff at the facility and added someone from nursing might have called the facility. They were queried how R901 was transported form their facility and they looked up on the computer and reported that R901 was transported in a wheelchair van by one of their transportation providers and provided their contact information. They had confirmed that no one from the facility accompanied R901 during the transfer on 10/3/24. An interview with the office staff for the (TS F) transportation provider was completed on 12/11/24, at approximately 12:20 PM. The call was placed by the facility administrator from their office. TS F was queried about the specifics of transport for R901 on 10/3/24. They reviewed their documentation and reported that they had provided the transport for R901 and the pickup was scheduled at 10:30 AM on 10/3/24. It was further reported they provided transportation one other time for R901 for an appointment and the driver noted during the transport R901 attempted to take off the seat belt and was not safe. The driver recommended having a staff member to accompany R901 for any future appointments. An interview with the DON was conducted on 12/10/24 at approximately 2:55 PM. They were queried about the facility's discharge planning process. The DON reported that discharge planning started on day one after admission into the facility and it involved their IDT, resident, or resident representative based on their goals. The DON was queried about R901's discharge and if they were involved in the process and/or had a meeting with the resident's representative. The DON reported that they did not meet with the resident representative, but the social worker and unit manager were involved. They added R901 had a language barrier and they were ambulatory and the unit manager might be able to provide additional information. A follow up interview with the DON was conducted on 12/11/24 at approximately 11:35 AM. They were queried on the expectation from their team with discharge/transfer process. The DON added the nursing staff reviewed the discharge instructions with the resident/resident representative if they were onsite or via phone. The DON was queried about their expectation for their staff to call to provide report the facility residents were transferred to and medication supplies during the transfer/discharge to another facility. The DON reported that it would be the best practice for the nursing team to call and provide a report to the facility that residents were transferred to, but it did not happen consistently. Also, the facility process was not to send any medications if residents were transferred to another skilled nursing facility. When queried further on medications that R901 needed to take that day until pharmacy was able to deliver their medications at the other facility, they reported that facility might be able to use their back up if those medications were available. An interview with the facility's Administrator was conducted on 12/11/24 at approximately 12:35 PM. During the interview they were queried about their expectations for discharge planning and facility-initiated discharge process and they reported that they expected their staff to follow the discharge planning policies and to keep the resident/resident representative/guardian involved in the process. R902 A complaint received by the State Agency revealed that R902 would like to move to another facility and had requested assistance from staff. R902 preferred to be in a private room and they were not getting updates from the facility. A review of R902's EMR revealed R902 was admitted to the facility on [DATE]. R902's admitting diagnoses included Parkinsonism, bipolar disorder, arthritis, diabetes, heart failure and Chronic Obstructive Pulmonary Disease (COPD). Based on the Minimum Data Set (MDS) assessment dated [DATE], R902 had intact cognition and needed supervision to minimal assistance from staff for their mobility and Activities of Daily Living (ADLs). An observation of R902 was completed on 12/10/24 at approximately 9:55 AM. R902 was observed in the bed watching television. R902 had a shirt and sheet covering their body. R902 stated, I want to get out this place, right now and added that they had already addressed this with the facility and no follow up has been made. R902 was upset. At approximately 12:25 PM, R902 was further interviewed. R902 reported they spoke with facility staff over a month ago about transferring to a different location and have not heard anything. An e-mail was sent to the facility administrator on 12/11/24 at 9:35 AM and they were asked to provide any grievances and follow-up for R902 from 9/1/24 to 12/10/24 and was notified that they did not have any grievances. Further review of of R902's EMR revealed a social work (SW) progress notes dated 10/7/24 that noted the social worker attempted to assess the resident, the resident was upset and asked to leave them alone. A SW progress note dated 10/21/24 at 13:34 revealed that a referral to other skilled nursing facilities were made by the social worker. A SW progress note dated 10/21/24 at 14:23 revealed that social worker had called the Ombudsman and notified that referrals were sent to five facilities that R902 had requested. The note read one admission director from one facility called and notified that they did not have any beds. Further review of EMR revealed no further follow-up with R902 or any referrals that were sent. An interview with SW B was completed on 12/10/24 at approximately 12:40 PM. During the interview they were queried about the R902's request to transfer to other facilities and their discharge planning. SW B reported that they were still working on placement and they had sent referrals to facilities in October. When queried if they had called the followed up with facilities and if they had spoken with R902 and provided updates. SW B reported that they had not spoken with any other facilities and had not spoken with R902 and did not provide any further explanation. On 12/10/24 at approximately 2:10 PM, SW B provided copies of the documents that were sent to other facilities. They reported that they were faxed over. There were no fax confirmations and they added they received call back from one facility and they did not have any beds. They had confirmed that they did not call to follow up and did not provide any updates since October 2024. An interview with Admissions Coordinator (AC) G from one of the facilities where R902's referral was sent was completed on 12/10/24 at approximately 2:20 PM. They were queried if they had received R902's referral and they reported that they received a fax. They were not a provider for R902's insurance carrier so they were not able to accept the resident and reported they must have notified the facility. A review of the facility provided document titled Discharge Summary and Plan read in part, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge .Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside. b. arrangements that have been made for follow-up care and services. c. a description of the resident's stated discharge goals. d. the degree of caregiver/support person availability, capacity and capability to perform required care. e. how the IDT will support the resident or representative in the transition to post-discharge care. f. what factors may make the resident vulnerable to preventable readmission; and g. how those factors will be addressed. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan . Another document provided by the facility titled, Transfer or Discharge, Facility Initiated dated 10/2022 read in part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Policy Interpretation and Implementation: Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. b. the transfer or discharge is appropriate because the president's health has improved sufficiently so the resident no longer needs the services provided by this facility. c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. the health of individuals in the facility would otherwise be endangered . Facility-Initiated Transfer or Discharge 1. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. 2. In some cases, residents are admitted for short-term, skilled rehabilitation under Medicare, but, following completion of the rehabilitation program, they communicate that they are not ready to leave the facility. In these situations, if the facility proceeds with discharge, it is considered a facility-initiated discharge. 3. A resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. 4. The facility will document that the resident or, if applicable, resident representative, received information regarding the risks of refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00139836. Based on interviews and record reviews the facility failed to ensure physician orders were transcribed and implemented as ordered by the Physician Assistant, ensure abnormal laboratory results were reported to the physician, ensure an EKG and echocardiogram was completed as ordered by the physician, and ensure the appropriate mode of transportation services were activated to transport the resident to the hospital for one (R909) of one resident reviewed for a change of condition, which resulted in the delay of care including the administration of antibiotics, treatment and medical services and required the resident to be transferred and admitted to the hospital for a higher level of care. Findings include: Review of the medical record revealed R909 was admitted to the facility on [DATE], with a readmission date of 11/10/19 and diagnoses that included: rhabdomyolysis, quadriplegia, lack of coordination and anoxic brain damage. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 (which indicated intact cognition) and required staff assistance with all ADLs. Review of a Physician Assistant progress note dated 8/28/23, documented in part . Patient is being seen at nursing's request. Nursing reports that patient was complaining of right lower quadrant abdominal pain last evening. Patient is seen currently lying in bed. He states that he is feeling short of breath . It is noted during exam that patient has intermittent cough appears to be guarding when he coughs. Patient is admitting to lower abdominal pain . Patient is appearing uncomfortable . Will get stat abdominal x-ray. Will get stat laboratory studies . Although patient is not tachypneic he is having episodes of decreased 02 saturations between 89 and 90%. We will get stat chest x-ray. Nursing is advised to apply 02 2 L (liters) via nasal cannula for 02 saturations less than 90% . Although patient has history of chronic pain and is on multiple controlled medications it is unusual for him not to be requesting an increase of both medications given the discomfort he is currently exhibiting. Patient will require close monitoring . Review of the medical record revealed an order for the administration of the oxygen to maintain a 90% saturation level was never transcribed and implemented as documented by the Physician Assistant. Review of a Nursing note dated 8/29/23 at 8:20 AM, documented in part . Xray report possible Bowel obstruction. MD (Medical Doctor) notified. New orders in place Dextrose-Sodium Chloride Intravenous Solution 5-0.45% (Dextrose w (with)/Sodium Chloride), Use 80 ml (milliters)/hr (hour)intravenously every shift for bowel rest for ileus for 2 Days . 12 lead ekg (electrocardiogram) - r/o (rule out) pericarditis, STAT (immediate) for r/o pericarditis - pleuritic chest pain, Pt (patient) is NPO (nothing by mouth) status . Review of a Physician note dated 8/29/23, documented in part . Review of abdominal x-ray is significant for an ileus . Patient indicates that he does not have abdominal pain but rather pain that began midsternal and has now moved to the right side of his chest and subcostal area . after awaking him he is breathing more quickly and shallowly. Pain seems as if it may be pleuritic. In questioning a possible pericarditis. I will initiate treatment with ibuprofen and check an EKG and echocardiogram looking for signs of pericarditis. We will also note any potential signs of right heart strain on the EKG as pulmonary embolism is also on the differential, albeit lower. If diagnostics are consistent with a pericarditis, we will also consider initiation of colchicine . Review of the physician orders revealed on 8/29/23 at 7:57 AM, a 12 lead ekg was ordered STAT and at 8:00 AM, an echocardiogram was ordered. Review of the medical record revealed no results of an EKG or echocardiogram to have been completed. Review of a Nursing note dated 8/29/23 at 7:16 PM, documented in part . writer is unable to successfully start iv (intravenous) on patient. Writer calls <sic> (third party name) to start iv . Review of the laboratory results collected on 8/28/23 at 6:37 PM and reported to the facility on 8/29/23 at 9:27 PM, documented multiple abnormal values, which included a [NAME] Blood Cell Count (WBC) of 17.1 (Reference Range- 3.5-10.6) which indicated a possible infection or inflammation in the body. Review of the medical record, Physician/Physician Assistant/Nurse Practitioner notes revealed no acknowledgment of the review of the laboratory results and/or the abnormal WBC count. Review of a Nursing note dated 8/30/23 at 8:29 AM, documented in part . Remain NPO (nothing by mouth) as ordered for bowel obstruction and is to start IV fluids via peripheral line. RN (Registered Nurse, RN Name) unable to start line. F/u (follow up) done with (third party name) RN . NP (Nurse Practitioner name) notified and order <sic> to start resident on Hypodermoclysis until peripheral insertion . Review of a Nursing note dated 8/30/23 at 11:25 AM, documented the third-party RN to have initiated a peripheral line in the right upper arm. Review of a Physician Assistant progress note dated 8/30/23, documented in part . Patient was seen recently in regards to feeling short of breath and abdominal pain . Patient has been placed n.p.o. An IV was unable to be established yesterday and patient was started on hydrodermoclysis <sic>. A midline IV has just been placed .Patient states he is not feeling any better. He continues to appear to be guarding with deep inspirations . Patient states that he feels like he has a fever although his temperature has been normal . Patient seen laying in bed appearing somewhat uncomfortable . Review of a Discharge/Transfer nursing note dated 8/31/23 at 8:41 AM, documented in part . Patient having abd (abdominal) pain and experiencing SOB (shortness of breath). Patient had recent ABD (abdominal) X Ray and Doctor wants patient sent out to rule out ABD obstruction . Transportation has been called and awaiting for arrival. Patient to be sent to (hospital name) . This note was documented by Licensed Practical Nurse (LPN) B. On 10/10/23 at 11:24 AM, LPN B was interviewed via telephone. LPN B was asked the presentation of R909 on 8/31/23 when they transferred the resident to the hospital and LPN B replied in part . I had literally just got on shift and did my rounds. I was concerned in what I was told in report, so I said let me check on him and when I went in there he was short of breath . He was short of breath and using his accessory muscles to breathe . When asked if the resident had on oxygen, LPN B replied No, everything was happening so fast that their thought process was to get the resident out to the hospital. LPN B was asked what transportation services they called to transfer the resident to the hospital and LPN B replied they called 911. Review of the record did not document which transportation services were called to transport R909 to the hospital. On 10/10/23 at 11:40 AM, the Director of Nursing (DON) was interviewed and asked the facility's protocol when a physician orders medications, treatments, or oxygen to be administered, the DON was asked if it was the physician or nurses' responsibility to transcribe and implemented the orders and the DON replied it was both. The DON stated the physicians, nurse practitioners and physician assistants will usually put in their own orders, or they may give a verbal to the assigned nurse. The DON was then asked why the oxygen orders were never ordered as directed by the physician assistant on 8/28/23 and the DON stated they would look into it and follow back up. The DON was then asked how the facility obtains the results of the labs ordered on the residents and the DON stated the results are sent through a portal to the electronic medical system in the residents' record. The DON stated if the labs are critical the laboratory will call the facility and inform the nurse. When asked whose responsibility it is to report to the physician any abnormal laboratory results for a resident with a recent change of condition the DON replied the nurse assigned to the resident. The DON was asked about the lab results for R909 that was provided to the facility on 8/29/23 that was never acknowledged or followed up by the facility's staff and clinicians and the DON stated they would look into it. The DON was also asked to provide the results of the EKG and echocardiogram that was ordered on 8/29/23. The DON was then asked to provide documentation on what transportation services was called to transport R909 to the hospital. At 1:38 PM, the DON returned and stated they did not see the oxygen order transcribed or implemented as ordered and documented by the physician assistant. The DON stated the EKG and echocardiogram were not done as ordered due to the facility ongoing issues with the third-party company. The DON stated they were not able to provide an explanation on why the labs were not documented as reviewed and reported to the physician. The DON then provided documentation of an actual wheelchair and specialty transport company (name withheld) that utilizes vans and minivans for wheelchairs and large party accommodations as the mode of transportation used to transport R909 to the hospital. The DON was asked why 911 was not called to safely transport the resident that was observed to be in distress and the DON stated initially the nurse (LPN B) did not feel that it was necessarily appropriate. The DON was informed of the interview conducted with LPN B to have described the distress that R909 was in when they observed the resident and the DON then stated they were unsure on why the nurse called the transportation services instead of 911 and the nurse had not been back to the facility since for them to follow up on this. The DON was then asked to provide any additional information or documentation that pertained to the above concerns. Review of a facility policy titled Laboratory, Radiology, and Other Diagnostic Services Guideline dated 6/1/20, documented in part . Purpose: To ensure laboratory, radiology and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment . Our facility is responsible for quality and timeliness of the services . The facility failed to follow their policy and ensure the laboratory results were reported to the provider and failed to ensure that the ordered EKG and echocardiogram was completed. Review of the transportation documentation provided revealed LPN B had not called 911 for transport of a distressed resident, but indeed called a transportation company to transfer the resident to the hospital. Review of a facility policy titled Notification of Changes Guideline revised 7/24/19, documented in part . A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication . In life threatening conditions activate the emergency response system immediately . This indicated R909 who was observed to have shortness of breath and utilizing their accessory muscles to breathe should have been transported to the hospital by the emergency response system, via 911 utilizing the Emergency Medical Services (EMS) who are qualified and trained medical personnel and who have the necessary equipment to safely transport the resident to a higher level of care to ensure timely treatment. Review of the hospital Internal Medicine History and Physical note dated 8/31/23 at 4:19 PM, documented in part . He states for the last 2 weeks he has experienced stabbing sensation over the right lower chest when he talks or takes a deep breath . He says has <sic> been couching with the feeling of sputum production but has not been able to get it out . PHYSICAL EXAM . In mild distress . Unable to inspire fully due to pain. Poor air movement . WBC (white blood cell count) 15.9 . HI (High) . CT (computerized tomography) Abd (Abdomen)/Pelvis: Large consolidations and loculated effusions at the right base empyema cannot be excluded . Chest x-ray: Interval development patchy airspace opacities in portions of the right mid and lower lung field since prior evaluation. Pneumonia is suspected until proven otherwise . CT Thorax: Pneumonia with a small, loculated right pleural effusion. Decreased image resolution limits evaluation for empyema . Impression and Plan Pneumonia, right middle and lower lobe, Right sided loculated pleural effusion . Cefepime (antibiotic) 2 g (grams) and linezolid (antibiotic) 600 mg in ED (Emergency Department) (Patient with parapneumonic effusion, empiric antibiotics started with IR thoracentesis (a procedure that uses imaging guidance and a needle to help diagnose and treat pleural effusions) with fluid analysis pending . Further review of the hospital record revealed the resident was admitted to the Intensive Care Unit (ICU) and had a VATS (Video-assisted thoracic surgery) procedure with a chest tube implemented for drainage. No further explanation or documentation was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely assess, monitor and follow physician orders for one R72 of one resident reviewed for hospitalization resulting in a decrease in R72's condition (sepsis) and hospitalization. Findings include: A review of R72's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: bipolar disorder, depression, dementia and atrial fibrillation. R72 was discharged to the hospital on 2/15/23. Review of R72's Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 6/15 (severely cognitively impaired) and required extensive one to two person assist for most activities of daily living. Continued review of R72's clinical record documented, in part, the following: 2/13/23 -Physician Progress Noted (authored by Physician Assistant (PA) H: .Patient seen recently due to weight loss and increased agitation .UA (urinalysis) C & S (culture and sensitivity) was ordered but has yet to be completed. Have discussed with nursing need to collect urine specimen via straight cath . *It should be noted that review of physician orders for R72 revealed an order dated 2/10/23 - Order Summary: Type of Lab cmp (comprehensive metabolic panel), Mg (magnesium), cbc (complete blood count) w/diff. As documented in PA H's note above there were no lab results until 2/15/23 in R72's clinical record pertaining to the 2/10/23 order. 2/13/23 (10:47 PM) - Heath Status Note (Authored by Nurse G): Resident observed in bed clammy, sweating profusely and tachycardic (increased pulse/heart rate) .BP (blood pressure) 146/87, P (pulse) 163.Spo2 (oxygen level) 89% .Writer called MD (Medical Doctor). Order received to put resident on 02 (oxygen) at 3L (liters) . It should be noted that review of R72's electronic record showed no order for O2 at 3L. There were no additional documents that indicated R72's O2 levels were monitored while on 3L 02. 2/13/23 (11:04 PM) SBAR (situation, background, assessment and recommendation) General Assessment: Situation: Name: R72 .what is the situation: Resident observed in bed tachycardia, clammy and labored breathing .Vitals (make sure the most current vitals are listed or you can add edit and update while completing the SBAR) : Blood Pressure -106/77 (date 2/7/23), Most Recent Pulse-61 bpm (date 2/7/23), Most recent Respiration- 20 breath/min (date 2/7/23), Most recent -Temperature 97.3 (date 2/7/23), O2 sats 91.0% (date 2/7/23) . Pain Level - 0 (date 2/12/23) .signs and symptoms .Hypoxia .Dyspnea .Weakness .confusion . *It should be noted that the vitals placed in the SBAR assessment were not current and dated as 2/7/23. There were no notes entered in R72's clinical record on 2/14/23. There were no vitals documented in R72's record for 2/14/23. The last electronic set of vitals noted in the resident's record was dated 2/7/23. Review of R72's MAR noted an order dated 4/18/22 that read Vitals BP/Pulse/Resp/Temp/02 Sats every evening shift. The response to the order was checked as completed however there was no indication as to the results of the vitals. The next note entered into R72's clinical record was dated 2/15/23 (11:27AM): .Resident has low BP 81/45 and tachycardic this morning .Resident encouraged to drink more fluids. Resident is cold and clammy with mottled Feet noted in bilateral extremities. (Authored by Nurse G) *It should be noted that this Note did not contain any information that indicated the resident's Physician was contacted. 2/15/23 (3:06 PM) Laboratory Results noted, in part: .White Blood Cell Count 15.6 (flagged as abnormal result (high) -usually meaning sign of infection) . 2/15/23 -Health Status Note: Order received from PA that was present in the facility at 4:30PM to send resident to ER (emergency room) for Hypotension and Tachycardia. Writer called EMT (Emergency Medical Transport) and resident was transferred to (name redacted) Hospital at 4:50 PM for further evaluation . (Authored by Nurse G) On 5/10/23 at approximately 11:05 AM an interview and record review were conducted with Registered Nurse G. Nurse G was queried as to the facility's protocol for obtaining resident's vitals. Nurse G reported that vitals should be obtained every shift. When asked where the results of the vitals would be located, Nurse G reported that they can be entered into either the MAR, resident notes or in the Vitals tab in the electronic record. When asked why they entered R72's vitals dated 2/7/23 into the SBAR/Assessment note dated 2/13/23 and again in the Discharge to Hospital assessment dated [DATE], Nurse G was not certain as to why, but noted the last vitals recorded may have populated into the form. When reviewing the Health Status notes with Nurse G it appeared as if there were no notes, vitals, assessments completed on 2/14/23. Nurse 'G was queried as to whether they endorsed their concerns to the oncoming Nurse and/or the Director of Nursing (DON). Nurse G reported that they believe they did, but they did not work on 2/14/23 and was not sure what happened on that day. When asked when they determined the resident had a low BP of 81/45 on 2/15/23 at approximately 11:27 AM did they contact the physician. Nurse G stated that they believed they did but did not record the conversation. On 5/10/23 at approximately 12:15 PM an interview and record review were conducted with the DON. The DON was queried as to R72's change in condition and delay in monitoring the resident's vitals, monitoring SP02 levels and a delay in obtaining lab orders. The DON reported that vitals should be noted at least daily in the resident's electronic record. With respect to orders pertaining to lab work, lab services are generally in the building on Monday, Wednesday and Fridays and more if STAT labs are ordered. With respect to R72, the DON noted that there should not have been such a long delay regarding the lab order. As for a lack of documentation regarding R72's vitals, the DON noted that they should be taken and recorded in the resident's record. When asked about the potential order for O2 at 3L, the DON stated that an order should have been entered and O2 levels should have been monitored. . On 5/10/23 at approximately 10:23 AM, an e-mail was sent to (name redacted) hospital requesting R72's hospital records with a start date of 2/15/23. Hospital records were received on 5/12/23 and a review of (name redacted) Hospital records documented in part, the following: .presents to ER on 2/15 . for abnormal blood work including high blood cell count and tachycardic at their facility. They were cold and clammy per reports .Pt (patient) now being managed for sepsis with antibiotics .Pt had gone into A-fib with RVR (rapid ventricular response) on admission .Assessment and Plan .patient has underlying dementia .stage IV pressure injury of the right heel .has been on IV antibiotic therapy .Sepsis likely from CAP (community acquired pneumonia) .Discharge Summary .Suspect Community Acquired Pneumonia . Pressure injury right heel .Present on arrival ,Wound care consult noted . *It should be noted that during the Survey review of R72's MAR/TAR had no documentation that R72 was being treated for a Stage IV pressure sore on the right heel. The facility policy titled Notification of Changes Guidelines (Revised 7.24.19) was reviewed and documented, in part: .Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representatives, and the resident's physician, to ensure best outcomes of care for the resident .