**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to notify the resident and resident's representative of a transfer or discharge in writing for one of one resident (R18) reviewed for hospitalization of 17 sampled residents. This created a potential for the resident or their resident representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process. Findings include: Review of a facility policy titled Transfers and Discharges, dated 05/12/23 indicated, .The facility will also provide transfer/discharge notice to the resident/responsible party in accordance with federal regulations .When residents are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges . There was no evidence in the facility's policy that addressed the requirement to send a written transfer notice to the resident and resident representative when there was an urgent medical need of the resident to be sent out to the hospital. Review of R18's electronic medical record (EMR) titled admission Record, indicated the resident was admitted to the facility on [DATE]. Review of R18's EMR titled alert note Progress Note, dated 07/17/23, indicated the resident sustained a fall. The resident was assessed, and the physician and representative were notified. On 07/19/23 the resident sustained a change in her condition and was transported to the local hospital for evaluation and treatment. Review of R18's EMR failed to contain evidence the resident and resident representative was provided with a written transfer notice which identified the location of where the resident was to be transported and appeal rights if the facility chose to readmit the resident back to their facility. During an interview on 09/09/24 at 11:32 AM, R18's family member (F) 1 stated she had not received any written transfer notice from the facility and stated she saves all of the resident's documents. During an interview on 09/10/24 at 11:14 AM, the Administrator stated that the facility has never given a written transfer notice to the resident and resident representative during an urgent medical need and transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure two Residents (R1 and R18) of three residents reviewed and/or their representatives were invited to participate in the resident's quarterly care plan meeting. In addition, the facility failed to ensure that the clinical records contained evidence that the residents and/or their representatives participated in the development or revision of the care plans. Findings include: Review of a facility policy titled .Comprehensive Care Plans and Conferences, dated 08/22/23 indicated, .The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team .The facility has a responsibility to assist residents to engage in the care planning process .The facility should provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation . 1. Review of R1's electronic medical record (EMR) titled admission Record, indicated the resident was admitted to the facility on [DATE]. Review of R1's EMR titled communication with family Progress Notes, dated 02/21/24, indicated the resident's responsible party was called and updated on the status of the resident. There were no other entries which indicated the resident and/or her representative were invited to participate in additional quarterly care conferences after this date. Review of R1's EMR titled quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 09/09/24 at 1:06 PM, R1 stated she was not invited to her quarterly care conferences. 2. Review of R18's EMR titled admission Record, indicated the resident was admitted to the facility 05/06/22. Review of R18's EMR titled annual MDS with an ARD of 06/27/24, indicated the resident had a BIMS score of eight out of 15 which revealed the resident was moderately cognitively intact. During an interview on 09/09/24 at 11:32 AM, R18's representative (F) 1 stated she had not been invited to the resident's care conferences. Review of R18's EMR titled communication with family Progress Notes, dated 02/08/24, indicated F1 participated in a care conference for the resident. There were no other entries which indicated the resident and/or her representative were invited to participate in additional quarterly care conferences after this date. During an interview on 09/10/24 at 8:43 AM, the Social Services Director (SSD) stated her process for inviting residents and/or their representatives included to call the family and alert the family of the upcoming care conferences. The SSD stated she would also send out a follow-up letter to the family too. The SSD stated she attempted to document the quarterly meetings. During a subsequent interview on 09/10/24 at 9:29 AM, the SSD stated did not document the invitations to R1 and R18's care conferences nor with their representatives. During an interview on 09/10/24 at 5:13 PM, the Administrator presented the facility's care conference policies and stated the policy did not address the quarterly care conferences.