Based on observation, staff interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for residents' use as evidenced by both facility's shower rooms being in disrepair for two (2) entrance areas of two (2) shower rooms in the facility. Findings include: Record review of facility's letterhead notification signed by the Administrator and dated 11/5/24, revealed, (Proper name of facility) does not have a specific policy for environment of care, concerning walls, etc. A policy is being developed immediately. During interviews and a tour with the Administrator and the Director of Nursing (DON) on 11/4/24 at 3:55 PM, it was revealed that each of the two locked shower rooms had an entrance area from the resident hallways that led to the shower area. Upon entrance into each of these areas, damage to walls and ceilings was observed. In the east hall shower room, the outside corner of the wall where people would walk or be assisted in a chair to the shower area had a large open area of missing plaster with visible metal grill like material. The ceiling around an air vent was also noted to be damaged with some plaster hanging down and a black substance on the open areas of the ceiling. In the south hall shower room, the ceiling surrounding the air vent was noted to have a large amount of damage and opened areas to the plaster with a dark substance noted near those open areas. The area behind the door where the doorknob met the wall was noted to be damaged with a large hole of missing plaster and metal noted inside. The DON stated the location and the necessity to pass through this area to enter the shower could lead to the potential for an injury and the areas needed repair. The Administrator revealed the entrance area to each of the two shower rooms had not been remodeled. She stated it had been mentioned to the maintenance department, but it was not repaired. She stated there was the potential for an injury to occur from this and it needed to be repaired. She confirmed the facility failed to provide a safe, functional, and sanitary environment for the residents' shower areas. During an interview and walk through observation with the Maintenance Director on 11/6/24 at 1:50 PM, it was revealed that he was aware of the damaged areas in each of the shower rooms. He stated he had been unsuccessful in finding someone to come in to do the necessary repairs, but he was attempting to contact another person to get the needed repairs completed. The Maintenance Director measured the damaged areas and in the east hall shower room, an area of an outer corner leading into the shower area measured approximately 22 inches from the top of the baseboard up the outer corner wall with a width of approximately 5 inches on one side of corner and 4 inches on the other side of the corner. This damaged area had a metal grill like material that was exposed. He confirmed the ceiling was missing plaster with open areas around air vent. This damaged area was measured approximately 25 inches x 18 inches with an open area with a black substance next to the air vent measuring approximately 8 inches by 1 inch. In the south hall shower room, the ceiling damage measured approximately 24 inches by 20 inches, with two open areas of a black substance next to the air vent measuring approximately 9 inches by 3 inches for one and approximately 2 inches by one inch for the other one. He stated he was unsure of what the dark substance on the open areas of ceiling was, but it could have been caused by the moisture. The area behind the south hall shower room door where doorknob met wall with an open area measuring approximately 5 inches by 4 inches with metal noted in the open area. The Maintenance Director confirmed he was aware of these damaged areas and that the areas needed to be repaired for safety.

Based on staff interviews, record review, and facility policy review, the facility failed to develop a care plan for hospice service for one (1) of 14 sampled residents' care plans reviewed. Resident #15 Findings include: Record review of the facility policy titled, MDS 3.0: Care Plans (Minimum Data Set) dated 6/23/16, revealed, The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: 1. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being as required, 2. Any services that would otherwise be required. Record review of Resident # 15's physician's Order Details revealed an order dated 5/9/24 to Admit to (proper name of hospice company) hospice. Record review of the care plans for Resident #15 revealed there was no care plan for hospice care and services. During an interview on 11/6/24 at 11:45 AM, the Minimum Data Set (MDS) Coordinator revealed Resident #15 was receiving hospice services and was assessed for hospice on the MDS assessment, but a care plan was not developed. She acknowledged any resident receiving hospice services should have a care plan for that care, and she was uncertain why this one was not done. She stated the resident had been on and off of hospice and this care plan just slipped through the cracks and was not done. An interview with the Administrator on 11/6/24 at 11:55 AM, confirmed Resident #15 was receiving hospice services, therefore, a care plan for this was needed. She stated that she was uncertain why the care plan was not developed. She acknowledged the care plan provided the staff with a guide for the care of each resident and should include the plans/treatments/preferences for each resident and the facility failed to develop a hospice care plan for this resident. Record review of Resident #15's Transfer/Discharge Report revealed the facility admitted the resident to the facility on 4/11/18. Record review of Resident #15's MDS Section O with Assessment Reference Date (ARD) of 8/12/24, revealed the resident was receiving hospice services. Section C revealed the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure the proper storage of a nebulizer facial mask and tubing to prevent contamination and the possibility of infection for one (1) of fourteen sampled residents. Resident #21. Findings Include: Record review of the facility policy titled Oxygen/Nebulizer and Continuous Positive Airway Pressure (CPAP) Supplies with a revision date of 03/13/18 revealed .Place Oxygen/Nebulizer tubing/supplies and CPAP mask/supplies in plastic bag after each use An observation on 11/04/24 at 10:40 AM, revealed a nebulizer machine on the nightstand next to Resident #21's bed and the facial mask and tubing were not in a plastic protective covering. An interview with Licensed Practical Nurse (LPN) #1 on 11/05/24 at 11:40 AM, confirmed that Resident #21's nebulizer mask and tubing were placed on top of the nightstand and were not inside a plastic protective bag. She revealed that a respiratory mask left open to air was an infection control issue, the mask could become contaminated with different germs and could cause respiratory infections. LPN #1 confirmed that the nebulizer facial mask and tubing should be in a protective covering when not in use. An observation and interview with the Administrator (ADM) on 11/05/24 at 11:45 AM revealed that nebulizer facial masks and tubing should be in a protective bag when not in use to prevent infection. She confirmed that Resident #21's nebulizer mask and tubing were placed on top of the nightstand and were not in a protective plastic bag. She revealed that leaving the nebulizer facial mask and tubing out and open to air could cause the spread of germs and respiratory infection. Record review of Resident #21's Order Summary Report revealed an order with a start date of 07/01/24 for Albuterol Sulfate Solution Nebulizer 0.5% (5 milligrams per milliliter) 1 dose inhale orally via nebulizer every six hours as needed for coughing/wheezing. Record review of Resident #21's November Respiratory Record revealed that she received an albuterol breathing treatment by nebulizer on 11/04/24 at 8:23 AM and on 11/04/24 at 5:09 PM. Record review of Resident #21's admission Record revealed an admission date of 08/21/20 and that she had diagnoses that included Shortness of Breath, Unspecified Dementia, and Chronic Obstructive Pulmonary Disease. Record review of Resident #21's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/05/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated that she had severe cognitive deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and facility policy review, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASARR) to the State Mental Health (SMH) Authority for a resident with a mental disorder (MD) following a significant change in mental condition for one (1) of three (3) PASARR's reviewed. Resident #23 Findings Include: Record review of the facility policy titled Pre-admission Screening with a revision date of 2/21/19 revealed, Policy: . c. If after admission, a resident is found to have a mental illness or the physician orders a psychotropic medication for the resident a Mississippi PASRR Level 2 Change in Status request will be submitted . Record review of the Medical Doctor progress notes dated 11/14/23 revealed that Resident #23 was placed on an intervention of one on one for suicide watch due to suicidal ideation's. Record review of the Nurses Notes dated 11/25/23 revealed that Resident #23 was transferred to Behavior Health. An interview on 1/25/24 at 8:25 AM, with Social Services revealed she sends in a status change when a resident has a new mental illness diagnosis added or has a change in mental or physical condition. She confirmed that she did not send in a status change for Resident #23 when he transferred to behavior health. She revealed that the resident was admitted to the facility with bipolar disorder and behavior health did not deem the resident as suicidal upon discharge, so she did not see this as a significant change in mental condition. She confirmed that the resident would benefit from psychiatric services. An interview with the Director of Nursing (DON) on 1/25/24 at 9:15 AM confirmed that with Resident #23's mental diagnosis of bipolar disorder and new symptoms of suicidal ideation, the resident should have had a change in status submitted to the SMH Authority. She revealed the resident would benefit from psychiatric services. Record review of the Face Sheet revealed that Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder and Depression Unspecified. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident #23 is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and facility policy review, the facility failed to implement a comprehensive care plan for monitoring a resident for suicidal ideation for one (1) of twelve care plans reviewed. Resident #23 Findings Include: Review of the facility policy titled MDS (Minimum Data Set) 3.0; Care Plans with a revision date of 6/23/16 revealed, Policy: The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required . Record review of Resident #23's Psychosocial Care Plan revealed under interventions, Monitor for suicidal ideation and was assigned to the role of Social Services. Record review of Resident #23's Anxiety Care Plan revealed, under interventions, Monitor for suicidal Ideation and was assigned to the role of Social Services. An interview with MDS Nurse on 1/25/24 at 2:15 PM, revealed the purpose of the care plan was to address the problem and diagnosis and develop a measurable goal to reach. She confirmed that Resident #23's care plan was not followed for monitoring for suicidal ideation. An interview with Social Services on 1/25/24 at 3:15 PM, revealed that she develops the Care Plans related to social services. She revealed that she did go by to see Resident #23 every morning, but she did not document anything. She confirmed that she didn't have any documentation to support that she monitored for suicidal ideation and confirmed the target care plan was not followed. Record review of the Face Sheet reveled the Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder, and Depression. Record review of the MDS with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident # 23 is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and facility policy review, the facility failed to provide or arrange for the necessary mental/psychosocial counseling services for a resident with a history of mental illness and suicidal ideation for one (1) of twelve sampled residents. Resident #23 Findings Include: Record review of the facility policy titled Social Service Program with a revision date of 5/10/16 revealed under, Policy: It is the policy of this facility to provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident. Also revealed under, Program Description: The Social Work Services Department is responsible for: . 4. Monitoring the resident's progress in improvement of physical, mental, and psychosocial functioning .6. Providing counseling services to residents and families . Record review of the Departmental Notes for Resident #23 dated 11/15/23 revealed the resident was transferred to behavior health due to suicidal ideation and returned to the facility on [DATE]. An observation of Resident #23 on 1/23/24 at 10:04 AM, revealed him lying in bed. The resident asked, Where am I? An interview on 1/24/24 at 2:00 PM, with the Administrator (ADM) revealed, to her knowledge, Resident #23 was not getting any psychiatric services before and following his recent behavioral health stay for suicidal ideation. She confirmed that with the resident's diagnosis of bipolar disorder, he would have benefited from these specialized services. She revealed the facility did not currently have a contract with any psychiatric services, and no referrals for Resident #23 to be seen by an outside source. An interview with Social Services on 1/25/24 at 8:30 AM revealed that when the resident was discharged back from behavior health, all that she knew about his stay was that he was not deemed suicidal. An interview with Social Services on 1/25/24 at 3:15 PM revealed that when Resident #23 returned from behavior health, she did go down to see him every morning, but she didn't document anything in the notes. She revealed that she didn't have a set schedule of when she visited Resident #23 and that she usually checks on every resident in the morning, but she didn't always document the things she had done. She confirmed that if the assessment was not charted, then it wasn't done. She confirmed that with no documentation, the facility could not show proof of providing services and support based on individualized resident needs. She revealed that no referrals had been made to any outside sources for the resident's mental health needs. Record review of Departmental Notes dated 11/29/23 revealed Social Services met with Resident #23 and his wife following behavior health stay. No documentation to support a psychosocial assessment was conducted. Record review of the Face Sheet revealed that Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder and Major Depression. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident # 23 is severely cognitively impaired. Also, revealed under Behavioral Symptoms in section E, the resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days, but less than daily during the MDS look back period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding for one (1) of five (5) residents reviewed for unnecessary medications. Resident #23 Findings Include: The facility provided the State Agency (SA) documentation on letterhead, (Proper Name of Facility) does not have a specific policy for monitoring for signs and symptoms of bleeding/bruising for residents on anticoagulant therapy. Record review of Resident #23's Medication Administration Record (MAR) revealed an order dated 7/14/23, Coumadin 7.5 mg (milligrams) by mouth every day except Wednesday for Circulation. Also revealed an order dated 10/20/23,Coumadin 2.5 mg tablet take one tablet by mouth on Wednesday for circulation. Both physician orders had a discontinuation date of 1/20/24. Record review of Resident #23's MAR revealed an order dated 1/21/24, Warfarin Sodium 5 mg tablet by mouth daily at 5 PM for circulation. Record review of the Physician order list and the Medication Administration Record (MAR) revealed there was not a monitoring tool for staff to monitor for signs of bruising and bleeding with the anticoagulant medication Coumadin. An interview with Licensed Practical Nurse (LPN) #1 on 1/24/24 at 1:20 PM, revealed that Resident #23 recently had a Coumadin dose change. She confirmed that they do not have a monitoring tool on the MAR to document any signs of bleeding or bruising. She revealed that when the aides put the residents to bed, they usually come and tell the nurse if they observed any bruising on the skin. An interview with Registered Nurse (RN) #1 on 1/24/24 at 1:25 PM, revealed they do not have a monitoring tool to alert the nurses to observe a resident on an anticoagulant medication for signs of bruising/bleeding. She stated, It's just something known. An interview with LPN #2 on 1/24/24 at 1:28 PM, revealed the facility does weekly body audits on all the residents and the aides were good at reporting any bruising or bleeding. An interview with the Director of Nursing (DON) on 1/24/24 at 2:50 PM, revealed the only monitoring they provided for the residents taking anticoagulant medication was a weekly skin audit. She confirmed lack of monitoring for anticoagulants placed the residents at risk for bleeding and death. Record review of the Face Sheet reveled the Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Atrial Fibrillation, Long Term (current) use of Anticoagulants, and Personal history of other Venous Thrombosis and Embolism. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6 which indicates Resident # 23 is severely cognitively impaired.

Based on observation, staff interviews, record review and facility policy review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents during two (2) of 10 medication observations. Findings Include: Record review of the facility policy titled, Medication Administration with a revision date of 6/07/16 revealed, .Essential Points: . 3. Never leave medication on top of medication cart unattended . During an observation of medication pass with Registered Nurse (RN) #1 on 1/23/24 at 11:15 AM, Resident #3 was ordered Novolog Insulin per sliding scale for a blood glucose reading of 285 mg/dl (milligrams/deciliter). RN #1 revealed the insulin was not stored on the medication cart, and she must go get the prescribed insulin from the medication room. Upon returning to the medication cart, RN #1 placed a clear open storage container on top of the med cart that contained nine (9) boxes of insulin and one (1) insulin pen. RN #1 entered Resident #3's room and administered the prescribed insulin and left the container filled with insulin on top of the medication cart unattended. RN #1 then entered Resident #12's room twice to perform a blood glucose check and then returned to give the prescribed sliding scale insulin while the plastic container filled with insulin remained unattended on top of the medication cart. An interview with RN #1 on 1/23/24 at 11:45 AM, revealed that they do not store insulin on the medication carts. She revealed the insulin was kept in the med room refrigerator in the plastic container. She revealed when they have glucometer checks, they bring the entire container of insulin out and return it to the medication room refrigerator when they are finished. She revealed that she left the insulin on top of the cart because the container was too big to fit inside the cart. RN #1 confirmed that the insulin should not have been left unattended on top of the cart due to the risk of a resident wandering by and picking it up. An interview with the Director of Nursing (DON) on 1/24/24 at 8:52 AM, revealed that anything could happen when medications were left on top of the medication cart unattended and confirmed that a resident could come by and take them. Record review of the Staff Meeting conducted December 2023 and January 2024 revealed, . No meds on top of med carts. Registered Nurse (RN) #1 was in attendance for both meetings.

Based on observation, staff interviews, record review and facility policy review, the facility failed to appropriately clean and disinfect a blood glucose meter between resident use for three (3) of nine (9) residents who require blood glucose finger sticks. Findings Include: Record review of the facility policy titled, Glucose Checks with a revision date of 6/07/16 revealed, .Procedure: . 8. Clean glucometer after use for a wet time of 2 (two) minutes using purple top sani-wipe . An observation of Registered Nurse (RN) #1 on 1/23/24 at 11:02 AM, revealed after she completed a blood glucose check for Resident # 3 using a multi-use glucometer, she used a Sani-cloth (purple top) disinfecting wipe to briskly wipe down the glucometer machine for approximately five (5) seconds and placed the machine on a napkin barrier to air dry. RN #1 then performed blood glucose checks for Resident #183 and Resident # 12 and followed the same process for disinfecting the blood glucose monitor after resident use. An interview with Registered Nurse (RN) #1 on 1/23/24 at 11: 45 AM, revealed that she usually wipes the glucometer down front and back and allows it to air dry according to the recommendation on the disinfecting wipes. She revealed she was unsure of the recommended wet time, but after reading the label on the wipes, she verified the wet time was 2 minutes. She revealed that she did not know that the wet time meant the blood glucose machine should remain wet (in contact with the disinfecting wipe) for a total of 2 minutes. She confirmed that she did not disinfect the machine properly and this was an infection control concern. An interview with the Director of Nursing (DON) on 1/24/24 at 9:02 AM, revealed the facility used Sani-cloth germicidal disposable wipes and the glucometers were to be cleaned between resident use. She revealed the nurses were to wipe the glucometers good and allow it to sit inside the wipe for 2 minutes. She confirmed improper disinfecting of the blood glucose monitor could spread infection. She revealed that all nurses had been recently in-serviced on the proper cleaning and disinfection of the multi-use glucometer. Record review of the Staff Meeting conducted December 2023 revealed, . cleaning equipment, including glucometers, with 2 min wet time for purple wipes. Registered Nurse (RN) #1 was in attendance. Record review of the Staff Meeting conducted for January 2024 revealed under, . cleaning equipment, including glucometers, with 2 min wet time for purple wipes. Registered Nurse (RN) #1 was in attendance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and facility policy review, the facility failed to provide the necessary behavior health care and services to a resident with a diagnosis of major mental illness for one (1) of 12 sampled residents. Resident #23 Findings Include: Record review of the facility policy titled Behavioral; Health Services with a revision date of 4/28/16 revealed, Purpose: Services are provided to meet resident's psychological needs. Resident behavior and emotional needs are closely monitored and evaluated to ensure that they do not become obstacles to treatment goals. (Proper Name of Facility) provides care and services to prevent and manage behavioral problems . Record review of the Departmental Notes for Resident #23 revealed the following entries: 11/5/23, Resident called for help repeatedly to get up and lay down. 11/7/23, He does not participate in many activity programs due to him having anxiety when around groups of people. 11/7/23, Resident did have behavior issues today. Resident refused lunch and states I will just starve to death. Hollering and cussing and saying he wants to die. 11/8/23, Resident makes statements like He's coming to the end of the road, He'll just starve to death . 11/9/23, Resident has been hollering this am, he has been upset wanting someone to help him with his breakfast . 11/11/23, Resident has been yelling Help, and I am blind. Record review of Doctor's Progress Notes for Resident #23 revealed an entry dated 11/14/23, Pt (patient) with some suicidal talk. He has on/off talk about depression. Will ref (refer) to behavior if this doesn't improve . Record review of the Departmental Notes for Resident #23 dated 11/15/23 revealed the resident was transferred to behavior health due to suicidal ideation and returned to the facility on [DATE]. An interview on 1/24/24 at 2:00 PM, with the Administrator (ADM) revealed we do not currently have a contract with any Psychiatric services. She revealed we are in the process of getting new behavioral health services; the company we were using voided our contract without notice due to their staffing shortages. She confirmed the facility had been without behavioral health services since Sept. 11, 2023. She revealed, to her knowledge, Resident #23 was not getting any psychiatric services before and following his recent behavioral health stay. She confirmed that with the resident's diagnosis of bipolar disorder, he would have benefited from these specialized services. An interview with Social Services on 1/25/24 at 8:30 AM, revealed that she was notified by the staff that Resident #23 was making suicidal threats. She revealed that she went down to talk with the resident that day, and he stated he did not plan to hurt himself. She revealed that she did a suicide risk assessment on the resident and rated him not suicidal. She revealed that she called the resident's wife regarding the issue, and she stated that the resident had never threatened to harm himself in the past, and this was new behavior. She revealed a referral was then sent to behavioral health. The Survey Agency inquired whether the resident was receiving psychiatric services before the recent behavioral health stay in November 2023, and she revealed he had not received any kind of psychiatric services since he was admitted to the facility. She revealed that when the resident was sent back from behavior health, all she knew was that he was not deemed suicidal during his stay. She revealed that behavioral health did not make any recommendations on discharge. She confirmed that the resident would have benefited from specialized psychiatric services before and following the behavior stay, due to his mental illness diagnosis. She revealed that the Administrator had been working to get psychiatric services in the building, but currently had not been able to find anyone. She confirmed that the facility was not providing services and support based on individualized resident needs. Record review of Resident #23's Medication Administration Record (MAR) revealed an order dated 11/29/23, Seroquel 50 mg tablet take one tablet by mouth twice day for Bipolar with behaviors. Also revealed an order dated 11/27/23, Zoloft 25 mg tablet one tablet by mouth daily for Major Depressive Disorder. Record review of the Face Sheet revealed the Resident #23 was admitted to the facility on [DATE] with medical diagnoses that included Anxiety Disorder, Bipolar Disorder and Major Depression. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of six (6) which indicates Resident #23 is severely cognitively impaired. Also, revealed under Behavioral Symptoms in section E, the resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days, but less than daily during the MDS look back period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the resident and/or resident's representative in writing of the reason for the transfer/discharge to the hospital for three (3) of four (4) residents reviewed. Resident #8, Resident #22, and Resident #39 Findings include: Resident #8: Record review of a typed letter on facility letterhead, dated 9/15/22 and signed by the Administrator revealed, To Whom It May Concern: This facility has looked and we cannot find a policy on notifying family members in writing when a resident is transferred from this facility. This facility notifies family members by telephone anytime a resident is sent to emergency room or to any other facility and this is documented in the medical record. This facility will immediately get a policy to notify family members in writing anytime a resident in transferred from this facility. Record review of the Departmental Notes dated 06/21/22 revealed Resident #8 was congested and had a cough, wheezing and crackles auscultated and his oxygen levels at 90% on 3 liters of oxygen when checked and was sent to the emergency room (ER) to be assessed. Record review of the Physician's Orders revealed order dated 6/21/22 to send to the emergency room to be assessed. The Resident Representative (RR) was notified by phone of transfer to the hospital. Record review of Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman revealed resident transferred to hospital on 6/21/22 and returned on 6/24/22 and Ombudsman was notified. Record review of Face Sheet revealed that Resident #8 was admitted to facility on 12/22/21 with diagnoses that included, Unspecified Dementia with behavioral disturbance and Chronic Obstructive Pulmonary Disease. Resident #22 Record review of a Departmental Note dated 7/12/22 at 2:58 PM, revealed the resident was difficult to arouse and had difficulty speaking and was sent to the ER for an evaluation. Record review of a Physician Orders revealed an order dated 7/12/22 to send to the ER for evaluation. Record review of Face Sheet revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus and Dementia. Resident #39 Record review of the Departmental Notes dated 8/6/22 at 3:44 PM, revealed a late entry for 8/5/22 that indicated Resident #39 had diminished breath sounds and complained of shortness of breath and was sent to the ER for evaluation. Record review of a Physician's Order dated 8/5/22, revealed an order to send the resident to the ER for evaluation. Review of Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included Malignant neoplasm of prostate, Hypertension and Dementia. An interview on 9/15/22 at 9:15 AM, with the Administrator confirmed Resident #8 was admitted to the hospital on [DATE], Resident #22 was admitted to the hospital on [DATE], Resident #33 was admitted to the hospital on [DATE] and Resident #39 was admitted to the hospital on [DATE]. She confirmed the RR's were not notified in writing of the reason for the transfer. The Administrator confirmed she was unaware of this requirement and the facility failed to provide the written notification with the reason for transfer to the resident or the RR. She confirmed the facility had no policy on this requirement.