**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #58 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #58 was not cognitively intact. She was able to ambulate with little assistance. The medical record demonstrated the resident was transferred to the hospital on 5/9/23 and due to a fall. Resident #58 returned to the facility on 5/16/23. No written notice of transfer was documented to have been provided to the resident or Ombudsman. The Social Worker (SW) was interviewed on 8/1/23 at 3:37 PM. She stated typically someone at the facility notified the Ombudsman when a resident was discharged from the facility, but added she was not the staff member responsible for notifying the Ombudsman. On 8/3/23 at 10:30 AM the Administrator stated she was not familiar with the transfer/discharge form that included a portion stating that the ombudsman should be notified of all discharges, including hospital transfers, from the facility. She stated the facility only sent written notification to a resident if it was a 30-day notice of discharge. She stated the facility had not been sending transfer/discharge notices when a resident went to the hospital. Based on resident and staff interviews, interview with the Ombudsman and record reviews, the facility failed to provide the resident a written notification for the reason for transfer to the hospital and failed to provide a copy of the transfer/discharge notice to the Ombudsman for 2 of 4 residents (Resident #56 and Resident #58) reviewed for hospitalization. Findings included: 1. Resident #56 was admitted to the facility on [DATE]. He was listed in the electronic health record as his own responsible party. The medical record demonstrated the resident was transferred to the hospital on 6/28/23 due to a change in condition. Resident #56 returned to the facility on 7/9/23. No written notice of transfer was documented to have been provided to the resident or Ombudsman. The significant change Minimum Data Set assessment dated [DATE] revealed Resident #56 was cognitively intact. On 8/1/23 at 3:26 PM an interview was completed with Nurse #1. She shared Resident #56 demonstrated a change in condition on 6/28/23 and she assisted with his transfer to the hospital. She explained when a resident was transferred to the hospital, the facility sent the following paperwork with the resident: medication administration record, face sheet, recent lab work, and clinical information about the resident. She said she had not sent a written transfer/discharge notice or provided one to Resident #56 when he was sent to the hospital. During an interview with Resident #56 on 8/2/23 at 10:15 AM, he said the facility had not provided him a written notice of transfer when he was sent to the hospital on 6/28/23. The Social Worker (SW) was interviewed on 8/1/23 at 3:37 PM. She stated typically someone at the facility notified the Ombudsman when a resident was discharged from the facility, but added she was not the staff member responsible for notifying the Ombudsman. A telephone interview was conducted with the Ombudsman on 8/1/23 at 3:57 PM. She reported the facility sent her a notice of transfer/discharge when a 30 day notice was provided to the resident by the facility. She said the facility had not sent her notification when a resident was transferred to the hospital and verified she had not been notified when Resident #56 was sent to the hospital. On 8/2/23 at 9:37 AM an interview was completed with the Executive Director. She stated the facility only sent written notification to a resident if it was a true 30 day notice. She verified the facility had not been sending transfer/discharge notices when a resident went to the hospital. She added the facility had kept a log of transfers to the hospital but had not sent the list to the Ombudsman. The Executive Director added it was the responsibility of the SW to send the list of discharges to the Ombudsman monthly, but there had been some changes in the SW department and it had not been consistently done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #58 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #58 was not cognitively intact. She was able to ambulate with little assistance. The medical record demonstrated the resident was transferred to the hospital on 5/9/23 and due to a fall. Resident #58 returned to the facility on 5/16/23. No written notice of the facility's bed hold policy was documented to have been provided to the resident's responsible party. The Business Office Manager was interviewed on 8/2/23 at 2:35 PM. She stated the bed hold policy was provided to a resident at the time of admission and then the nurse in charge during the time of transfer would provide anything else that was needed. On 8/3/23 at 3:30 PM, the Executive Director stated that the bed hold policy was provided to the resident and/or resident representative during admission and it was part of the admission documents. She stated she was not aware they needed to send the bed hold policy each time a resident was transferred to the hospital. She also stated that the facility recently moved to computer generated transfer packets and the bed hold may have been a part of the packet in the past but was inadvertently omitted currently. Based on resident and staff interviews and record reviews, the facility failed to provide the resident a written notification of the bed hold policy upon a resident's transfer to the hospital for 2 of 4 residents (Resident #56 and Resident #58) reviewed for hospitalization. Findings included: 1. Resident #56 was admitted to the facility on [DATE]. He was listed in the electronic health record as his own responsible party. The medical record demonstrated the resident was transferred to the hospital on 6/28/23 due to a change in condition. Resident #56 returned to the facility on 7/9/23. No written notice of the facility's bed hold policy was documented to have been provided to the resident. The significant change Minimum Data Set assessment dated [DATE] revealed Resident #56 was cognitively intact. On 8/1/23 at 3:26 PM an interview was completed with Nurse #1. She shared Resident #56 demonstrated a change in condition on 6/28/23 and she assisted with his transfer to the hospital. She explained when a resident was transferred to the hospital, the facility sent the following paperwork with the resident: medication administration record, face sheet, recent lab work, and clinical information about the resident. She said she had not sent the bed hold policy or provided one to Resident #56 when he was sent to the hospital. During an interview with Resident #56 on 8/2/23 at 10:15 AM, he said the facility had not provided him a copy of the bed hold policy when he was sent to the hospital on 6/28/23. The Business Office Manager was interviewed on 8/1/23 at 3:33 PM. She explained the bed hold policy was provided to a resident at the time of admission. Additionally, the charge nurse provided the bed hold policy to the resident when they were transferred to the hospital. On 8/2/23 at 9:37 AM an interview was completed with the Executive Director. She stated staff were supposed to send the bed hold policy when a resident was transferred to the hospital. She explained the nurses used to send a packet of information with the resident that included the bed hold policy. Recently, the facility transitioned from a packet of information that was kept at the nurse's desk to computer generated forms and nurses hadn't included the bed hold policy when they sent a resident to the hospital.

Based on observations and resident and staff interviews, the facility failed to post the availability of the facility's survey results. This practice had the potential to affect all residents in the facility. Findings included: During a tour of the facility including the secured unit on 03/17/22 at 9:06 AM an observation was made that survey results were not posted. There was no notice posted in the facility regarding the availability and location of recent survey results. On 03/17/22 at 9:10 AM Resident #19, the Resident Council President revealed she had no knowledge of the location of the survey results notebook. She stated she was not aware where they were located and had not seen any signage that directed residents to their location. On 03/17/22 at 9:17 AM an interview with a Nurse #1 working on the secured unit revealed there was no survey results notebook on the secured unit. She stated the results were up front. She further stated if family asked about the results, she would take them up front and find them On 03/17/22 at 9:20 AM in an interview with a Nurse Aide #1 regarding the location of the survey results, she stated I would assume they would be up front. She indicated if family asked for the results, she would locate them and inform the family of their location. On 03/17/22 at 9:22 AM in an interview with the Activity Director she indicated the results were posted at the front. On 03/17/22 at 9:22 AM during an interview with the Administrator she pointed at the file holder outside her door where the survey results book was observed. She stated there used to be a sign on the file holder that indicated it contained the survey results notebook. She further stated the results were not posted anywhere else in the facility. She indicated to her knowledge there were no signs posted anywhere else in the facility indicating the location of the survey results. On 03/17/22 at 11:40 AM in a follow-up interview with the Administrator she stated she expected signage to be posted at all nurse stations and in the lobby indicating the location of the survey results. She further stated she expected survey results and the location of survey results to be discussed in Resident Council and that all newly admitted residents were to be made aware of their location.