**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of progress notes revealed Resident #8 was transferred from the facility with the anticipation to return on 02/26/22. The resident returned on 03/04/22. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. 3. Review of the progress notes for Resident #26 revealed she was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. 4. Review of the nursing progress notes for Resident #27 revealed he was discharged to the hospital on [DATE] and returned to the facility on [DATE]. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. 5. Review of the nursing notes for Resident #44 he discharged to the hospital on [DATE]. The medical record . During interview on 05/10/22 at 3:35 P.M., Business office Manager (BOM) #112 stated she does not notify the family or resident in writing of discharge notification. Based on record review, interview and policy review, the facility failed to notify the resident, representative or Ombudsman in writing of a transfer from the facility. This affected five (Residents #5, #8, #26, #7 and #44) of five residents reviewed for transfer notices. The facility census was 39. Findings include: 1. Review of progress notes revealed Resident #5 was transferred to the hospital on [DATE] and 05/01/22. The medical record contained no documentation of a written notification of transfer to the resident, representative or Ombudsman. During interview on 05/10/22 at 11:10 A.M., Resident #5 stated he did not receive any information related the transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #08 revealed she was admitted to the facility on [DATE] and discharged to a facility out of state on 05/09/22. Her diagnosis included, acute kidney failure, hydronephrosis, unspecified protein-calorie malnutrition, essential primary hypertension, paroxysmal atrial fibrillation, history of traumatic brain injury, encephalopathy, gastro-esophageal reflux disease. Review of the quarterly minimum data set (MDS) 02/20/22 revealed Resident #08 had impaired cognition as evidenced by a brief interview for mental status (BIMS) score of 12. Resident #08 required extensive assistance with bed mobility, walking on the unit, dressing, toilet use, personal hygiene, and supervision from staff with eating. Review of Resident #08's nursing progress notes revealed Resident #08 discharged from the facility with the anticipation to return on 02/26/22. Further review of the nurse's charting for Resident #08 revealed she returned to the facility on [DATE]. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. 3. Record review for Resident #26 revealed an admission date of 01/01/20. Her diagnosis included coronavirus 2019 (covid-19), displaced intertrochanteric fracture of left femur, unspecified protein calorie malnutrition, hyperglycemia, dementia without behavioral disturbance, and impaired cognition. Review of the quarterly MDS assessment, dated 04/04/22, revealed Resident #26 had severely impaired cognition as evidenced by her BIMS score of 04. Further review of the MDS assessment revealed Resident #26 required limited assistance from staff with transfers, walking, toilet use, personal hygiene, dressing, bed mobility. She required supervision from staff with eating. Review of the progress notes for Resident #26 revealed she was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. 4. Record review for Resident # 27 revealed an admission date of 09/04/20. His diagnosis included end stage renal disease, covid-19, cholecystitis, unspecified protein-calorie malnutrition, cognitive communication deficit, delirium, and gout. Review of the quarterly MDS assessment, dated 04/05/22, revealed Resident #27 had moderately impaired cognition as evidenced by a BIMS score of 09. Resident #27 required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. Further review of the MDS assessment revealed Resident #27 was totally dependent on staff with transfers, walking, and bathing. However, he only required supervision from staff with eating. Review of the nursing progress notes for Resident #27 revealed he was discharged to the hospital on [DATE] and return to the facility on [DATE]. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. 5. Review of the nursing notes for Resident #44 revealed an admission date of 04/13/22 and he discharged to the hospital on [DATE]. His diagnosis included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, protein calorie malnutrition, hypothyroidism, gastroesophageal reflux disease. Review of the five-day MDS assessment, dated 04/18/22 revealed Resident #44 was moderately cognitively impaired as evidenced by his BIMS score of 10. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility and was totally dependent on staff with assistance with transfers. Resident #44 required supervision assistance from staff with eating, toilet use, personal hygiene, and bathing. Review of the nurse charting for Resident #44 revealed he was discharged to the hospital on [DATE]. Further review of the nursing progress notes did not reveal verification of notice of transfer or information regarding a bed hold notification. Interview on 05/10/22 at 3:30 P.M. with the Admissions and Marketing Representative #111 stated she does not notify the family/residents in writing of bed hold policy. Interview on 05/10/22 at 3:35 P.M. with the Business office Manager (BOM) #112 confirmed she does not notify the family or resident in writing of bed hold policy. Interview on 05/10/22 at 3:36 P.M with the Clinical Director of Operations #110 confirmed the facility has not notified resident or resident families of bed hold policy on or before transfer. Interview on 05/11/22 at 12:59 P.M. with Registered Nurse (RN) #54, via phone interview, verified she transferred resident to the hospital on [DATE] stated she sent face sheet and medication list with emergency personnel. Interview on 5/12/22 at 11:30 A.M. with Unit Manager Licensed Practical Nurse (LPN) #31 stated the nurses send a medication list and a face sheet with all transfers and appointments. Unaware of any additional documents that is provided to the resident regarding the bed hold policy. Review of the facility policy titled Bed Hold dated 04/2018 and reviewed 01/2022 revealed the facility failed to implement the policy as written. Number three states in the event of an emergency transfer to the hospital, the facility social worker or designee will attempt to contact the resident or resident representative within twenty-four hours of the transfer and determine whether to [NAME] the resident's bed. The facility will document multiple attempts if necessary to reach the resident and or the resident representative in case when the facility was unable to notify. Based on medical record review, staff interview, observations and facility policy review, the facility failed to ensure a written bed hold policy was given to the resident prior to transfer from the facility. This affected five residents (#8, #5, #26, #27, #44) of five residents reviewed for bed hold policy. The facility census was 39. Finding include: Medical record review for Resident #5 revealed an admission on [DATE] with diagnoses including end stage renal failure, intestinal malabsorption, iron deficiency anemia, renal dialysis, type two diabetes, depression, peripheral vascular disease, and hypertension. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 revealed an intact cognition. Resident #5 requires total assist for bed mobility and transfers. Resident #5 required extensive assist for eating and toileting. Review of the plan of care for Resident #5 dated 12/09/21 revealed resident has behaviors related to placing calls to 911 multiple episodes without reason and after medical assessment. Interventions include engage resident in self-care and physical activities to channel energy, encourage ventilation of feelings, fears and anxiety, reinforce and focus on reality, and do not confront resident's belief system. Review of the Progress note for Resident #5 dated 10/28/21 at 11:36 A.M. as a late entry for 10/21/21 at 11:19 A.M revealed resident called 911 for transfer to the hospital. Review of the Progress notes for Resident #5 dated 10/21/21 through 10/26/21 when resident was readmitted to the facility was silent for transfer notice to resident or resident representative. Review of the Progress note for Resident #5 dated 05/01/22 at 10:52 A.M. revealed resident complained of pain in his toe. Acetaminophen 500 mg given however resident called 911 and went to the hospital. The medical record was silent for transfer notice to resident or resident representative. Observation on 05/10/22 at 11:09 A.M. of Resident #5 revealed resident resting in bed with eyes closed. Awakened easily with knock on door. Interview on 05/10/22 at 11:10 A.M. with Resident #5 stated he did not receive any information related the transfers. Further stated the facility staff give all the papers to the squad when they come and get me. Interview on 05/10/22 at 3:30 P.M. with the Admissions and Marketing Representative #111 stated she does not notify the family/residents in writing of bed hold policy. Interview on 05/10/22 at 3:35 P.M. with the Business office Manager (BOM) #112 confirmed she does not notify the family or resident in writing of bed hold policy. Interview on 05/10/22 at 3:36 P.M with the Clinical Director of Operations #110 confirmed the facility has not notified resident or resident families of bed hold policy on or before transfer. Interview on 05/11/22 at 12:59 P.M. with Registered Nurse (RN) #54, via phone interview, verified she transferred resident to the hospital on [DATE] stated she sent face sheet and medication list with emergency personnel. Interview on 5/12/22 at 11:30 A.M. with Unit Manager Licensed Practical Nurse (LPN) #31 stated the nurses send a medication list and a face sheet with all transfers and appointments. Unaware of any additional documents that is provided to the resident regarding the bed hold policy. Review of the facility policy titled Bed Hold dated 04/2018 and reviewed 01/2022 revealed the facility failed to implement the policy as written. Number three states in the event of an emergency transfer to the hospital, the facility social worker or designee will attempt to contact the resident or resident representative within twenty-four hours of the transfer and determine whether to [NAME] the resident's bed. The facility will document multiple attempts if necessary to reach the resident and or the resident representative in case when the facility was unable to notify.

Based on observation and interview, the facility failed to ensure nursing staffing information was posted daily. This affected all 30 residents at the facility. Findings include: Observation on 06/30/19 at 8:00 A.M., upon entrance to the facility revealed posted nursing staffing information dated 06/28/19 was on a table across from the receptionist desk. Interview on 06/30/19 at 9:31 A.M. with the Administrator verified the posting nursing staffing information was for 06/28/19 and reported the receptionist was to change to staffing sheet daily to reflect the current date but had not arrived to work yet and must have forgot to change the sheet yesterday.