**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #1) of three residents reviewed for discharge planning. The facility failed to implement an effective discharge plan for Resident #1, when FM S reported the resident's home was without electricity. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could place residents at risk of not receiving care, supervision, and services to meet their needs upon discharge. Findings included: Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/31/2025. DX included: Acute kidney failure (failing kidney function), unspecified dementia (cognitive decline), abnormalities of the gait, unsteadiness on fee, Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), hypokalemia (low potassium levels). Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected Resident #1 had no history of wandering, section GG for resident functional abilities were left empty, indicating she was not assessed at discharge on [DATE]. Section N - Medications reflected the resident was not taking any high-risk medications. The discharge MDS was not signed by authorized personnel. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #1 was at risk of falls. Review of Resident #1's Fall risk Assessment at her time of admission dated 03/12/2025 reflected that she was a moderate risk for falls, scoring a 7, indicating some fall interventions were needed based on Falls r/t confusion. Review of Resident #1's Elopement Risk Assessment at her time of admission dated 03/12/25 reflected Resident #1 was cognitively impaired with poor decision-making skills .no pertinent diagnosis for dementia, resident does not ambulate independently, no vision, hearing, or communication problems, no history of elopement, leaving without needed supervision, or wandering aimlessly. The resident was not at risk of elopement/wandering at this time. Record review of progress note dated 03/28/2025 at 2:48 PM by NP reflected Assessment and Plan: Impaired mobility and gait worsened state since PTA, continue rehabilitation efforts with multidisciplinary approach including PT for gait, OT for self-care skills and transfers. - Pt currently will benefit from continuous 24 hr. care for medication, skin care, education, and reinforcement in therapies along with psychiatric medical care/recommendations for ongoing medical issues. Will need to include family education/training and possible DME assessment -Precautions: Fall, Skin Acute Metabolic Encephalopathy [a brain dysfunction caused by a sudden imbalance in the body's metabolism, leading to changes in brain function, such as confusion, disorientation, or memory loss.] oriented X 3, baseline dementia. Previous records, history, pertinent labs, imaging were reviewed and discussed with pt. The above plan was also discussed with pt at depth who states understanding and agrees. PMR (Physical Medicine and Rehabilitation. It is a medical specialty that focuses on restoring function and improving mobility in patients with musculoskeletal, neurological, and spinal cord injuries) will continue to follow this pt and give recommendations, intermittent management for above noted medical issues purely as role of consulting service per facility, IM/Primary/attending team's request. Record review of Resident #1's progress note dated 3/31/2025 at 9:29 PM, NP reflected suspected progressive dementia - supportive care. Record review of Resident #1's MD orders dated 03/12/2025 reflected the following: Hypoglycemic Protocol: Follow Hypoglycemic Protocol if blood sugar is less than 70 mg/dl (a unit of volume equal to one-tenth of a liter.) Assessment tab when protocol is required every shift -Start Date- 03/12/2025 6:00 PM -DC Date-04/01/2025 3:54 PM 03/12/2025 HS snacks .Monitor resident for abnormal bruising and/or bleeding from nose, gums, blood in urine or stool Q Shift every shift .order dated 03/26/2025 reflected .Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth every 8 hours as needed for Anxiety .Hydroxyzine Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety. Record review of progress note dated 03/31/2025 at 3:57 PM by ADM reflected APS referral completed upon discharge from facility on 3/31/25 at 3:45 PM. Worker Intake ID [number]/Report number [number] to 1800-252-5400. APS referral completed due to concerns from the cousin that patient is returning to an unsafe living environment where the cat has urinated/poop all over her apartment, no food, and maybe no lights available. Record review of Resident #1's Discharge Plan of Care dated 04/04/2025 reflected Resident # 1 was being discharged to home with family, nursing needs: wheelchair .transportation: family transported. Scheduled appointments: f/u with PCP .CM explained care/support to resident caregiver, yes no special instructions for diet .treatment reviewed with resident/caregiver, yes .APS referral made with resident discharge home d/t cognitive decline. This note was added after the resident discharged by CM T as a late entry. During an interview with the ADM on 04/11/2025 at 9:40 AM, revealed Resident #1's was discharged on 03/31/2025 at 3:40 PM. ADM said FM S was aware of the discharge home, and home health had been contacted. ADM said FM S had reservations closer to the discharge date stating she was afraid of Resident #1, Resident #1 can't live with her, the home was not safe due to the electric power being disconnected. ADM stated that she did not contact the apartment manager for information on Resident #1's home environment prior to discharge. ADM told FM S she would have Resident #1 transported to the apartments via Uber (transportation business). ADM said she did not attempt to search for other family prior to discharge. ADM said Resident #1 discharged home on a previous stay, and this was the discharge plan at the time of admission on [DATE]. She denied behaviors of cognitive loss and confusion. She said the resident was capable of returning home to care for herself. She notified APS of the home condition allegations from FM S as an alternate plan for Resident #1 when she left the faciity on [DATE]. During a phone interview with FM S on 04/11/2025 at 10:20 AM said she told the ADM that the home did not have electricity. FM S said she did not agree with the ADM goal to discharge home, because Resident #1 was confused, and no services were set up prior to her return home. FM S told the ADM that she would not be living in the home with Resident #1, and she proceeded to discharge home. FM S said there were additional extended kin for the Resident #1, but they were not contacted nor informed about the discharge planning and return home. FM S said that the facility did not ensure home health services were scheduled prior to discharge. FM S said that Resident #1 did not have a walker or wheelchair when she arrived at the apartment, only personal belongings. During a phone interview with the ADON T on 04/11/2025 at 10:40 PM she stated that Resident #1 was a skilled patient under her supervision. She stated Resident #1 was frequently confused and cognitively impaired. She could ambulate independently throughout the facility, but she would not be able to live alone without supervision due to her dementia. ADON T was aware that Resident #1 was being discharged home with cousin and home health services. During a phone interview with the HCM K on 04/11/2025 at 2:10 PM she stated on 03/31/2025 Resident #1 was transported to the hospital by KR K after observing she was confused, and the apartment was not safe and sanitary for Resident #1 to live. HCM K said Resident #1 after medical hospital assessments, the ER staff determined that due to the level of her memory loss, she should not be left at home alone to care for herself due to cognitive loss. During an interview on 04/11/2025 at 6:40 PM with KR K she stated that she was a family member of Resident #1. KR K reported that FM S have excluded her from the rehabilitation contact, therefore she was not aware that Resident #1 had been discharged on 03/31/2025. On 03/31/2025 (time unknown) KR K said she received call from Resident #1 and her neighbor at 5:00 PM requesting that she pick her up, because her electricity was disconnected. KR K said Resident #1 remained with the neighbors until she arrived at 6:00 PM. KR K could not find the neighbors phone number and name. KR K said she contacted KR C to meet her at the apartment. KR K said she and KR C arrived and went to the third floor and Resident #1 was with the neighbor. She immediately took Resident #1 to her car and asked KR C to remain with her while she checked the apartment. KR K said the apartment had no electricity and there was cat food, feces, and urine on the floor. KR K contacted FM S to find out what happened. KR K said the family member was not responsive. KR K said she and KR C explained to Resident #1 that they had to take her to the hospital for an evaluation until the home environment safety and utilities were connected. KR K said Resident #1 was somewhat confused and could not provide details of the day leading up to her calling. KR K and KR C took Resident #1 to the hospital, and she was admitted . KR K said the hospital placement was temporary and a means for getting assistance with another placement. During an interview with CM T on 04/25/2025 at 1:13 PM revealed she completed the hard copy of the Discharge plan and Resident #1 signed at the bottom that she understood. She was not aware of her confusion; she was directed by the IDT and ADM to discharge the resident home with HHC. CM T stated that the facility does not conduct home visits to assess for safety. CM T said she would not have notified the apartment complex of the discharge or uber transport to the complex on 03/31/20205. CM T stated that it was her understanding that FM S would be present to take custody and care of Resident #1 once the uber arrived. CM T stated that additional task and plans were provided to FM S by the ADM. CM T said she left the PCP name empty because the resident did not know the name and contact information. CM T did not set up the intake of HHC, nor followed up with a call after discharge to ensure patient connection for services. CM T said at discharge the Resident was provided the name and contact number of the HHC agency to call upon arriving home. During an interview with RN G on 04/14/2025 at 1:22 PM revealed she observed the discharge of Resident #1. She assisted with transferring her into the uber with personal belongings. She signed the hard paper copy of the discharge planning on 03/31/2025. RN G said she did not complete the discharge plan of care assessment in the electronic records system. During an interview with the DOR on 04/14/2025 at 1:28 PM revealed rehabilitation staff were involved in the discharge process, and her role would require her to attend the IDT for resident status in therapy and reviewing resident discharge form payment providers (insurance) and schedule date. DOR said once a NOMNC she and her staff will provide family education training and ensure the resident and family were prepared for a discharge home. DOR said additional task and assessment for the resident included notifying all if additional equipment was needed at home such as, DME Durable medical equipment assess. The DOR said the therapy department will provide the social worker with this information to continue with discharge. The DOR said Resident #1 was compliant with therapy, she confused and was observed with impaired cognition. The recommendations were to discharge home with home health services and additional therapy assessments for services in home. During an interview with the DON 04/14/2025 at 2:30 PM she stated that the goal was for Resident #1 to return home, and APS was notified of home environment concerns by the ADM after the resident discharged home. She said the resident wanted to return home. The DON said she did not have any concerns with Resident #1 living alone in her apartment. The DON said home health services were set up for FM S to call and schedule for an assessment. The DON said resident was observed with occasional confusion, however, she lived alone prior to admission to the facility and the goal was for her to return home. The DON said FM S reported to the ADM that Resident #1's home was not safe to live prior to departure. The DON said it was at that time the ADM told FM S that she would make an APS report about the condition of the home. The DON said it was not until later that she was notified that the resident was sent to the hospital. During an interview with APSI on 04/15/2025 at 12:44 PM she stated the facility ADM called in an APS report on 03/31/2025. APSI said the resident should not have been returned home if the electricity was disconnected. APSI said there was a current investigation since Resident #1 entered the hospital. She stated she was working with the hospital staff for placement. She said Resident #1's cognitive loss prevents her from living alone at home. During an interview with the HSW on 04/15/2025 at 4:10 PM she stated that the resident was adjusting and would not be discharged at this time until a suitable placement was found. HSW said Resident #1 should not be left at home alone to care for herself due to cognitive loss. During an interview with hospital HRN on 04/25/2025 at 10:00 AM she stated that Resident #1 was adjusting to the hospital stay. HRN said Resident #1 was still very confused and would not be able to live alone at home at this time. HRN said there was no discharge date being considered at this time, they were continuing to monitor her care. During an interview with CM T on 04/25/2025 at 12:50 PM, she stated that she had not completed the discharging planning form in the electronic records, however she had the information to document on a note in her office. She stated that the discharge planning form should have been completed immediately after the discharge to provide the information provided to the resident. During an interview with LSW on 04/25/2025 at 6:25 PM she stated that discharge planning should be coordinated with all disciplines to ensure safety. She stated that residents without a confirmed RP or POA would remain at the facility until a safe discharge plan was confirmed to ensure, resident's safety. She said cognitively impaired residents should not be sent home to live alone. She stated that CM T was under the social services department, however she was not consulted on Resident #1's discharge 03/31/20 25, because CM T discharged residents that were here for short term skilled services. LSW said she will contact the HHC, DME and other services for aftercare to ensure scheduling of the services and equipment prior to discharging from the facility. She said failing to follow up with services could result in the resident not having the aftercare and needed equipment to function at home. During an interview on 04/26/25 at 12:35 PM with the ADON N she said all care plans should be completed timely and accurately to guide the resident's care needs while at a skilled facility and address the plan of discharge. Failure to complete and document discharge plans in the care plan could lead to goals for aftercare not being met. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The following Plan of Removal was accepted on 04/26/2025 at 1:22 PM for immediate actions to ensure residents were not in jeopardy of harm. The Plan of Removal provided reflected the following: Plan of Removal - F660 submits the following Plan of Removal for the alleged failure to develop an effective discharge planning process. By submitting this plan of removal does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? 1. The following plan was implemented to ensure the discharge planning is effective immediately on 4/25/2025 for all upcoming discharges: a. Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided. b. Discharge paperwork will be presented to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. c. A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney. d. Post discharge services such as home health will be set up prior to discharge. e. Physicians and NP's will be notified of discharges to address resident's needs. f. Resident #1 no longer resides at the facility. How were other residents at risk to be affected by this deficient practice identified? 1. All residents discharging from the facility have the potential to be affected by this alleged deficient practice. What does the facility need to change immediately to ensure that residents have a safe discharge from the facility and to ensure that this does not happen again? a. An in-service was completed on 4-11-25 with the Administrator by the Regional [NAME] President of Operations that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. b. An in-service was completed on 4-11-25 with the social worker and case manager by the Administrator that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. c. An in-service was completed on 4/11/25 with the IDT team by the administrator regarding the completion of the discharge summary, notifying the Physicians and NP's of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. d. All discharges will be reviewed by the IDT team in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed. e. All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/ or administrator will contact the ombudsmen and seek assistance if needed for guardianship. How will the system be monitored to ensure compliance? a. The DON/Designee will review all discharge orders for upcoming discharges for completion daily for the next week and three times a week for the following 6 weeks. b. The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs daily for the next week and three times a week for the next 6 weeks. c. The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health daily for the next week and three times a week for 6 weeks. Quality Assurance An impromptu (unplanned) Quality Assurance and Performance Improvement review of the removal plan will be completed on 4/25/25 with the Medical Director for agreement with this plan. Monitoring of the POR included: Record review of in-service training report dated 04/11/2025 by RD with ADM time unknown, reflected Appropriate discharge planning include the following steps: Discharge summary completion, communication of discharge orders, confirmation of home health orders information of on discharge transportation, Notification of discharge to RP/POA and resident if cognitive. The ADM signature was observed on page 2 confirming attendance. Record review of facility Inservice titled Discharge Plan of Care Completion UDA's department managers dated 04/2025 time unknown by ADM reflected Please ensure that the discharge plan of care UDA's (User defined assessments) are completed within 48 hours of discharge. Discharge summaries are to be completed within 48 hours of discharge. Ensure that the physician and NP assigned to the resident is notified of the upcoming discharge to address any additional resident needs. The facility will ensure that discharge paperwork will be signed by only cognitively intact residents and/or responsible party on power of attorney. Signatures of staff that participated in the in-service, CM T, LSW, ADON, LVN E, DON, LVN K, and MDS R. the date of the in-service was not dated at the top or bottom of the in-service. Record review of facility Inservice titled discharge date d 04/11/2025 time unknown by ADM, reflected to ensure appropriate discharge planning of residents and to ensure safe discharge time following items have been completed: 1. Family members of RP will be required to pick up residents. 2. We will no longer provide courtesy transportation. 3. RP will sign discharge. 4. Discharge will only be signed by a cognitive party/resident and or family member. Signatures of staff that participated in the in-service, CM T, LSW, MDS D, LVN M, RN H, RN G, LVN S, LVN R, LVN O, LVN A, LVN B. Record review of in-service titled dated April 25, 2025, by ADM for the dual services department/ social services titled discharge planning reflected to ensure residents safely discharge back their prior settings, Family members will be required to provide their own transportation. Family members will be required to sign discharge paperwork. Staff signatures LSW P and CM T. LSW and CM T signature was observed on page 2 confirming attendance. Record review on 04/26/2025 of Residents #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 were reviewed for residents with discharged planning completion from the facility on or after 04/08/2025. The charts indicated appropriate notifications were made and the resident's discharges were safe. Interviews were conducted on 04/26/2025 with ADM, DON, ADON N, MDS R, LSW, CM T, RN G (1st shift), RN H (2nd shift), LVN S (2nd shift), LVN O (2nd shift), LVN L (1st shift), LVN J (1st shift) RN U (1st shift) training on discharge planning for residents included: ensuring the resident's POA/RP were present at discharge to transport from the facility; ensure medications were reviewed POA/RP and assess for understanding and document in electronic system; ensure aftercare providers are notified ( HHC, DME .) prior to discharge; ensure that the POA/RP were educated and comprehend the discharge directions prior to discharge; Notify the POA/RP were notified and educated on the residents care needs, medications, doses, treatments, therapies, symptoms, signs of change, notifying the MD of concerns: provide MD/PCP contact information for a follow up appointment in two weeks; ensure the POA/RP have the pharmacy locations where prescriptions will be sent; ensure the POA/RP have knowledge of the delivery timeframe for DME; ensure that nursing/social services staff follow up with aftercare services and MD/PCP to confirm resident client service status: ensure who and where the resident will be living and if supervision was needed or left alone; ensure cognitively impaired residents are not transported via public transportation; ensure and call assessments, care plan, and MDS are completed prior to discharging the resident, and ensure the NP and MD were notified prior to discharge of date, plan, and time of discharge in order to obtain additional services and approvals for the resident to discharge. The staff said that follow up calls would be conducted to confirm follow up appointments and services for aftercare. Record review of facility policy Titled Transfer or Discharge Documentation Policy Statement dated December 2016 red in part When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: a. The basis for the transfer or discharge; Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's Attending Physician: The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; or The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. the receiving facility's service(s) that are available to meet those needs. That an appropriate notice was provided to the resident and/or legal representative The date and time of the transfer or discharge; The new location of the resident; The mode of transportation; A summary of the resident's overall medical, physical, and mental condition. Others as appropriate or as necessary; and Comprehensive care plan goals; and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The Administrator was informed the Immediate Jeopardy was removed on 05/26/2025 at 5:45 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that when the facility anticipated discharge of one (Residents #1) of three residents reviewed, there was a discharge summary that included a recapitulation of the resident's stay. The closed records for Residents #1 that were reviewed did not contain facility discharge summaries that included a recapitulation of the residents' stay, signature of FM S/RP/POA confirmation of aftercare services for a resident that was impaired cognitively on 03/31/2025. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could result in incorrect, incomplete, or misleading information being recorded regarding discharged residents. Findings included: Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/31/2025. DX included: Acute kidney failure (failing kidney function), unspecified dementia (cognitive decline), abnormalities of the gait, unsteadiness on fee, Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), hypokalemia (low potassium levels). Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected Resident #1 had no history of wandering, section GG for resident functional abilities were left empty, indicating she was not assessed at discharge on [DATE]. Section N - Medications reflected the resident was not taking any high-risk medications. The discharge MDS was not signed by authorized personnel. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #1 was at risk of falls. Record review of Resident #1's progress note dated 03/28/2025 at 12:49 PM by RN G resident is A&O X 1, with confusion. continue. to require assist with ADL. Record review of progress note dated 03/31/2025 at 8:31 AM by RN G reflected Resident remain in stable condition, respirations even unlabored no distress noted denies pain at this time, on cont. ABT/UTI, no adverse reaction noted, PO fluids offered and encouraged as tolerated, will cont. with care. Record review of Resident #1's Physician discharge summary completed by NP RB dated 03/31/2025 reflected provisional diagnosis: Acute Kidney Failure, unspecified Condition at discharge stable .Discharge Diagnosis: aftercare acute kidney failure unspecified Prognosis: Fair. Disposition: home by uber. [name] home health. DME - NA signed by NP RB . Record review of Resident #1's Discharge summary dated [DATE] completed by CM T reflected. Transportation to discharge location by taxi Home health agency [name], Patient has all needed DME the section for appointment scheduled with .date/time .reason .phone was left blank [Pharmacy name and location], Primary Care Physician name, address, phone .DR unknown to patient. The form was signed by CM T on 03/27/2025 and RN G on 03/31/2025 .Resident #1's signature and dated 03/03/2025. The attending physician name written in print [MD A]. During an interview with the facility CM T on 04/14/2025 at 11:00 AM she stated that Resident #1 was confused at times, but overall, she was able to meet all of her care needs, walk independently, and communicate her needs. CM T said Resident #1 lived alone prior to admitting on 03/12/2025 and was able to care for herself at home. CM T said she did provide HHS referral for the family, and it was provided to FM S on 03/27/2025. CM T said she did not contact the apartment where Resident #1 lived to inquire about the safety and condition of the apartment or if the electricity was working. CM T said she later was told the resident's electricity was disconnected and she was in the hospital. During an interview with RN G on 04/14/2025 at 11:30 AM she stated she escorted Resident #1 up to the front and transferred her in the uber car. RN G said Resident #1 was confused most of the time and needed assistance at times. RN G said Resident #1 was not capable of living at home alone due to her dementia and cognitive decline. During an interview with the ADM on 04/11/2025 at 9:40 AM, revealed Resident #1's was discharged on 03/31/2025 at 3:40 PM. ADM stated that the family member participated in Resident #1's plan of care and discharge planning after the insurance company ended the 21 day rehabilitation stay. She stated that FM S became distant the day before the discharge home. FM S told the ADM she was afraid to transport the resident home in her car. ADM said FM S did not say the reason she was afraid of Resident #1. ADM stated that she scheduled and uber driver to transport the resident to FM S at the apartments. FM S told ADM that the apartment was unsafe for Resident #1 to live in due to the environment floor being covered with cat feces and urine, and the electricity was disconnected for non-payment. The ADM stated that she would notify APS to report unsafe conditions, because the facility does not conduct home visits to determine a safe environment for discharge residents. The ADM stated that she contacted APS and made a report, transferred resident in the uber with personal items, and remained on the phone with FM S while the resident was transported, where she waited. Once the resident arrived at the apartment the call was terminated. ADM said she did not have the contact information (name and number) of the uber driver or number. On 04/01/2025, ADM said she received a call from FM S reporting the resident was transported to the hospital by a friend of the family. FM S said Resident #1 did not return home with any devices for mobility. During an interview with ADON T on 04/11/2025 at 10:15 AM, she stated that Resident #1 was a patient that resided on her hall. She said the resident was confused and had interventions to address her dementia. She said though she could independently ambulate through the facility, the staff had to redirect resident and provide segmented task. She said Resident #1 was discharged to her apartment with the family and home health services on 03/31/25. The ADON W did not know that Resident #1's apartment did not have electricity. The ADON T said Resident #1 should not live alone, due to confusion and cognitive decline with dementia. During a phone interview with FM S on 04/11/2025 at 10:20 AM she said that she did not sign the discharge summary, nor did she agree with the discharge home, due to the unsafe environment concerns (no electricity, pet feces and urine throughout the apartment, and spoiled food.) FM S said she was notified by the ADM on 04/27/2025, that Resident #1's insurance days had ended as of 03/31/2025. FM S said the ADM further stated that the resident could not remain at the facility for long term, due to not having an ID. FM S told the ADM that she (FM S) would not pick the resident up from the facility, and Resident #1's home was not safe, because she would be living alone, the electric power was disconnected, and cat feces and urine covered the apartment floor. FM S said ADM agreed to pay for an Uber to transport Resident #1 home. The ADM agreed to remain on the phone with FM S until the resident arrived at the apartment complex. The ADM did not provide any additional information about the uber driver or his car. FM S said she was not aware of how discharge worked; and was not the POA for Resident #1. FM S said once Resident #1 arrived, she instructed the [NAME] to bring the resident to her apartment and allow entrance into her apartment, because FM S lost her key. FM S remained downstairs in her car observing [NAME] and Resident #1 entering the apartment. FM S said [NAME] told her that Resident #1 was confused and asked the whereabouts of the restroom as she did not recognize her apartment. FM S left Resident #1 upstairs in her apartment alone, while waiting for law enforcement to arrive. FM S stated the ADM instructed her to call 911 for law enforcement to come out and assess the apartment for safety once Resident #1 arrived at the apartment. FM S said she remained downstairs until she received a call from KR K that she had picked up Resident #1 and transported her to the hospital, because the Resident's electricity was turned off. FM S said she did not attend any care plan meeting for Resident #1 while she a patient and the ADM and nursing staff were told many times. FM S said she did not sign any forms, nor did she agree to the resident returning home. During an interview with [NAME] T on 04/11/2025 at 1:00 PM she stated that on 03/31/2025 she observed Resident #1 entering the apartment office and sitting in the lobby. [NAME] said Resident #1 was observed confused, stating she had just returned from work by Uber. Resident #1 then asked to renew her lease. [NAME] told Resident #1 that her lease was current, and no action was needed at this time. [NAME] called FM S to report that Resident #1 was in the office confused. [NAME] said FM S asked her to bring Resident #1 to her apartment and unlock the door. [NAME] said she and Resident #1 arrived at the apartment and she unlocked the door and allowed her to enter. [NAME] said Resident #1 appeared confused when the door opened and asked for the location of the restroom. [NAME] departed the apartment and observed FM S downstairs in her car. The [NAME] said that Resident #1 did not have a walker or wheelchair when she arrived at the apartment, only personal belongings in plastic bags. The [NAME] did notify FM S of Resident #1's confusion while entering the apartment. During an interview with the Resident #1 on 04/14/2025 at 9:45 AM she stated she was brought to the hospital by KR K and KR C after she called for help. Resident #1 said her electricity was disconnected when she returned from a hospital. Resident #1 said after departing the hospital, she took an uber to her apartment to check on her cat, then to the hospital. Resident #1 was very confused and could not recall the events of discharge, home, then to hospital. Resident #1 said she does not trust anyone due to them reporting she was confused and could not return home. Resident #1 was observed in the hospital bed dressed in 2 hospital gowns, hair groomed, body and environment clean. During an interview with ADON T on 4/25/2024 at 12:35 PM, she said that she initiated the discharge planning after Resident #1 was discharged . ADON N said the task was observed in the electronic record system as needing to be completed, so she completed the nursing portion of the form. She stated that the facility policy did not specify the timeline for completing the discharge planning. She stated that the discharge planning form has not been completed for it to be locked as completed. She stated that CM/SW needed to complete the pharmacy section and close out the form. During an interview with CM T on 04/25/2025 at 12:50 PM, she stated that FM S did not come to the facility for the discharge summary, so the information was provided by phone. CM T said that Resident #1 was asked to sign the discharge summary and the information about HHC, medication, and MD were provided, and she stated that she understood. The CM T stated that the ADM and DON contacted FM S to set up transportation home for Resident #1. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The Plan of Removal was accepted on 04/26/2025 at 1:22 PM for immediate actions to ensure residents were not in jeopardy of harm and reflected the following: Plan of Removal - F 661 Methodist Transitional Care Center submits the following Plan of Removal for the alleged failure to complete a discharge summary. By submitting this plan of removal does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? 1. The identified Resident no longer resides in the facility. How were other residents at risk to be affected by this deficient practice identified? 2. All residents discharging from the facility have the potential to be affected by this alleged deficient practice. What does the facility need to change immediately to ensure that residents have a safe discharge from the facility and to ensure that this does not happen again? 1. An audit was initiated on 4/14/25 ongoing to ensure that the discharge plan of care/summary was completed, Discharge Summary completed and reviewed with an appropriate family representative, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed. 2. An in-service was completed with the Administrator regarding discharge planning by the Regional [NAME] President of Operations on 4/11/25. 3. An in-service was completed with the social worker and case manager regarding discharge planning by the Administrator on 4/11/25. 4. An in-service was completed with the IDT team regarding the completion of the discharge summaries, notifying the Physicians and NP's of discharges to address resident's needs, providing discharge paperwork to the power of attorney or appropriate family representative, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge by the Administrator on 4/11/25. 5. The Corporate Clinical Service Director reviewed facility policy on 04/11/2025 regarding completing the discharge summary and no revisions were deemed necessary. 6. All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/ or administrator will contact the ombudsmen and seek assistance if needed for guardianship. How will the system be monitored to ensure compliance? d. The DON/Designee will review all discharge orders for upcoming discharges for completion daily for the next week and three times a week for the following 6 weeks. e. The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs daily for the next week and three times a week for the next 6 weeks. f. The Administrator/Designee will audit all discharges for discharge summaries, Discharge Summary completed and reviewed with an appropriate family representative when applicable, discharge location, means of transportation, and confirmation of home health daily for the next week and three times a week for 6 weeks. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the removal plan will be completed on 4/25/25 with the Medical Director for agreement with this plan. The facility took the following actions to correct the non-compliance: Monitoring of the POR included: Record review of facility Inservice dated 04/11/2025 time unknown by ADM reflected Discharge Summary LSW/CM T must ensure that discharge planning completed for all residents, discharge summary must be completed for home health orders, DME orders were completed. To ensure Residents safely discharge back to their prior settings family members well be required to provide their own transportation. Record review of facility Inservice by DON on 04/25/2025 with the nursing department titled Discharge/Discharge Planning, dated 4/25/2025, reflected when discharging a resident, education is performed [with] resident and RP/POA on all medications. Discharge summary [with] home health if needed and DME. Resident will be asked to follow up [with] PCP within 14 days. Signatures of staff that participated in the in-service, CM T, LSW, MDS D, LVN M, RN H, RN G, LVN S, LVN R, LVN O, LVN A, LVN B. Record review on 04/26/2025 of Residents #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 were reviewed for residents who discharged planning completion from the facility on or after 04/08/2025. The charts indicated appropriate notifications were made and the resident's discharges were safe. Interviews were conducted on 04/26/2025 with ADM, DON, ADON N, MDS R, LSW, CM T, RN G (1st shift), RN H (2nd shift), LVN S (2nd shift), LVN O (2nd shift), LVN L (1st shift), LVN J (1st shift) RN U (1st shift) training on completing discharge summaries thoroughly and ensure all information was documented. Ensure a meeting with the IDT prior and discharge summary to ensure all needed information, cognition, and ability to safely transfer to after care service with the necessary equipment. Ensure comprehension of the services and notifications for assessments once they are discharged . The Social Services and Nursing Services will assign a staff to conduct a follow call to providers for the resident status of services. The POA/RP and MD signatures documented on the form confirming that they were in agreement with the discharge summary, knowledge of the discharge summary of events, needed services, and referrals and aftercare. The staff will ensure that all information was completed when residents were discharged . Notify the ADM of residents that are unable to discharge home safely due to cognition, supervision, or limited abilities safely discharge home. Record review of facility policy Titled Discharging the Resident December 2016 read in part The purpose of this procedure is to provide guidelines for the discharge process Discharging the resident to home or another long-term care facility: Who will be providing the resident's care (i.e., nurses, assistants, therapists, etc.). That his or her family and visitors will be informed of the discharge and where the resident will be living .Transport the resident to the pick-up area. Assist the resident into the automobile. Assist the family in loading the president's personal effects. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions. The Administrator was informed the Immediate Jeopardy was removed on 05/26/2025 at 5:45 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident reviewed for one (Resident #1) of four residents reviewed for Administration. The ADM and DON failed to ensure residents discharged home were provided the appropriate supervision and care before returning home. The ADM directed staff to discharge Resident #1 home without knowing she was diagnosed with dementia, confusion, altered mental status, and no POA. The IDT failed to notify the NP/MD of Resident #1's discharge home alone without services. The ADM, DON, and CM T returned Resident #1 to an unsafe home environment without investigating and following up prior to sending her home in an Uber (ride share). An Immediate Jeopardy (IJ) situation was identified on 05/08/2025 at 11:00 AM after an administrative review determined that the noncompliance would be elevated to an IJ. The ADM was provided an IJ template and told that the current POR (Plan of Removal) that was accepted on 04/26/2025 at 1:22 PM was sufficient. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure placed residents at risk of not receiving the appropriate care and services to maintain their highest practicable well-being and at risk of a diminished quality of life and supervision for safety. The findings included: Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/31/2025. DX reflected unspecified dementia (cognitive decline), Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), hypokalemia (low potassium levels). The face sheet did not list a POA or RP, only emergency contact #1 (FM S) and the name and phone number of FM J. Record review of Resident #1's entry MDS assessment, dated 03/12/2025 reflected entry date of 03/12/2025 from the hospital to a skilled nursing facility. Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected Resident #1 had no history of wandering; section GG for resident functional abilities was left empty, indicating she was not assessed at discharge on [DATE]. Section N - Medications reflected the resident was not taking any high-risk medications. The discharge MDS was not signed by authorized personnel. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #1 was at risk of falls. Record review of Resident #1's MD orders dated 03/12/2025 reflected the following: Hypoglycemic Protocol: Follow Hypoglycemic Protocol if blood sugar is less than 70 mg/dl (a unit of volume equal to one-tenth of a liter.) Assessment tab when protocol is required every shift -Start Date- 03/12/2025 6:00 PM -DC Date-04/01/2025 3:54 PM 03/12/2025 HS snacks .Monitor resident for abnormal bruising and/or bleeding from nose, gums, blood in urine or stool Q Shift every shift .order dated 03/26/2025 reflected .Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth every 8 hours as needed for Anxiety .Hydroxyzine Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety. Record review of Resident #1's progress note dated 03/28/2025 at 12:49 PM by RN G resident is A &O x 1 (alert and oriented times) indicating that she knew her name but not where they are, what time it is or what is happening, with confusion. cont. to require assist with ADL. Record review of Resident #1's progress note dated 03/28/2025 at 2:48 PM by the NP reflected Assessment and Plan: Impaired mobility and gait worsened state since PTA, continue rehabilitation efforts with multidisciplinary approach including PT for gait, OT for self-care skills and transfers. - Pt currently will benefit from continuous 24 hr care for medication, skin care, education, and reinforcement in therapies along with psychiatric medical care/recommendations for ongoing medical issues. Record review of Resident #1's progress note dated 3/31/2025 at 9:29 PM, by the NP reflected suspected progressive dementia - supportive care. Record review of Resident #1's insurance dated 03/30/2025 titled Medicare coverage of current skilled nursing services will end on 03/30/2025. Verbal notification given patient or RP on 03/27/2025. Additional information reason unable to sign cognitive impairment NOMNC given to [FM] via telephone the beneficiary's last day of coverage 03/30/2025 and the date when the beneficiary liability is expected to begin 03/31/2025 informed [FM] that appeal must be done as soon as possible, but no later than 12:00 noon of the day before the last covered day [FM] plans to take member to home on [DATE]. Record review of Resident #1's Physician discharge summary completed by NP RB dated 03/31/2025 reflected provisional diagnosis: Acute Kidney Failure, unspecified Condition at discharge stable .Discharge Diagnosis: aftercare acute kidney failure unspecified Prognosis: Fair. Disposition: home by uber. [name] home health. DME - NA signed by NP RB. Record review of Resident #1's ADON N Discharge Plan of Care dated 04/04/2025 reflected Resident # 1 was being discharged to home with family, nursing needs: wheelchair .transportation: family transported. Scheduled appointments: f/u with PCP .CM explained care/support to resident caregiver, yes no special instructions for diet .treatment reviewed with resident/caregiver, yes .APS referral made with resident discharge home d/t cognitive decline. This note was added after the resident discharged by CM T as a late entry. During an interview with Resident #1 on 04/25/2025 at 10:00 AM at the hospital revealed she was interviewable, confused and could not recall daily routines, where she lived, nor her discharge home details. She had lost her ID card, purse, and cell phone. She couldn't recall the last time she used the items. During a phone interview with FM S on 04/11/2025 at 10:20 AM revealed that she did not attend any meetings as an RP during Resident #1's stays at the facility. FM S told the ADM that the home did not have electricity and that Resident #1 would be living in the home alone. FM S said that the facility did not ensure home health services were scheduled prior to discharging Resident #1 home alone. FM S said she did not agree with the ADM goal to discharge Resident #1 home, because Resident #1 was confused, and no services were set up prior to her return home. FM S said the ADM proceeded to discharge Resident #1 home despite her concerns. FM S said there were additional kinship relations of FM J (RK K and RK C), however, they were not contacted nor informed about the discharge planning and return home. FM S said that Resident #1 did not have a walker or wheelchair when she arrived at the apartment, only personal belongings. FM S said she was waiting in her car at Resident #1's apartment when the driver left her at the apartment complex. FM S asked the [NAME] to bring Resident #1 to her apartment and allow entrance, because she did not have a key. FM S said once [NAME] escorted Resident #1 in her apartment and departed in a golf cart. During an interview with the ADM on 04/11/2025 at 9:40 AM, revealed Resident #1's was discharged on 03/31/2025 at 3:40 PM. ADM said FM S was aware of the discharge home, and home health had been contacted. ADM said it was the RP's responsibility to call HHS and schedule a visit to the home for an assessment. ADM said FM S had reservations closer to the discharge date stating she was afraid of Resident #1, Resident #1 can't live with her, the home was not safe due to the electric power being disconnected. ADM stated that she did not contact the apartment manager for information on Resident #1's home environment prior to discharge. ADM told FM S she would have Resident #1 transported to the apartments via Uber (transportation business). ADM said she did not attempt to search for other family prior to discharge. ADM said Resident #1 discharged home on a previous stay, and this was the discharge plan at the time of admission on [DATE]. She denied behaviors of cognitive loss and confusion. She said the resident was capable of returning home to care for herself. She notified APS of the home condition allegations from FM S as an alternate plan for Resident #1 when she left the faciity on [DATE]. During an interview on 04/11/2025 at 6:40 PM with KR K she stated that she was not related to Resident #1. KR K reported that FM S have excluded her from the rehabilitation contact, therefore she was not aware that Resident #1 had been discharged on 03/31/2025. On 03/31/2025 (time unknown) KR K said Resident #1 was somewhat confused at times. KR K said resident lived alone and was discharged home from the facility in 12/2024. KR K said the facility staff did not contact her during Resident #1's stays 03/12/2025. KR K said the hospital placement was temporary and a means for getting assistance with another placement. During an interview with the facility CM T on 04/14/2025 at 11:00 AM she stated that Resident #1 was sent home after a NOMNC discharge for insurance payment ending. The ADM directed CM T to complete the discharge summary on 03/27/2025 (see record review for discharge plan). CM T and ADM called FM S to transport Resident #1 home; however, FM S refused and did not want to be responsible for the care of Resident #1. CM T said the ADM notified the FM that Resident #1 would be discharged home today via paid public transportation, because FM S agreed to the discharge home in the NOMNC via phone. FM S told the ADM that the resident would be living alone, the apartment electric power was disconnected, the apartment was soiled with cat feces and urine, and the environment was not safe for the resident to live. CM T stated that she had notified the HHS of the resident discharge home and the need for an assessment of after care services. During an interview with the DON on 04/14/2025 at 2:30 PM revealed Resident #1's FM agreed to the courtesy transport, and she would be waiting at the complex for Resident #1, then called and stated the home was not safe and sanitary for Resident #1 to live in due to the utilities not working. DON said the FM told the ADM that the home was not safe prior to sending her home via uber. The DON and the ADM were notified after the discharge that the FM was not present to receive the resident at the home location. the ADM and DON stated that the resident payment insurance days had ended, and the FM knew the plan to discharge the resident home at the time of admission. The DON said the resident did not have an identifying information to pursue Medicaid or an additional placement at the time of the discharge. The ADM told the FM she would contact APS to for a report regarding the unsafe home environment. During a phone interview with NP on 04/25/2025 at 10:45 AM she stated that Resident #1's confusion and cognition was progressive, and she required supervision if discharged home. During an interview with the DON on 04/26/2025 at 5:05 PM she stated that in the future residents would no longer be transported via courtesy transportation at the expense of the facility. The DON said she would ensure the MD was included in the discharge planning in the IDT meeting, seek additional clinical guidance from members prior to discharge to ensure resident safety. The DON said she would report all concerns involving RP and POA's to the ADM. During a second interview with the ADM 04/25/25 at 5:25 PM she stated that changes to the facility discharge included no courtesy transports from the facility for discharged residents. She would notify the ombudsman and leadership of a resident's changes in condition, the need for a responsible representative and additional resources before sending an impaired cognitive resident home to live alone. The ADM said that the ADM, DON, ADON, CM, SW, MD, MDS, and DOR was a part of the IDT. During an interview with LSW on 04/25/2025 at 6:25 PM she stated that discharge planning should be coordinated with all disciplines to ensure safety. She stated that residents without a confirmed RP or POA would remain at the facility until a safe discharge plan was confirmed to ensure, resident's safety. She said cognitively impaired residents should not be sent home to live alone. She stated that CM T was under the social services department, however she was not consulted on Resident #1's discharge 03/31/2025, because CM T discharged residents that were here for short term skilled services. LSW said she will contact the HHC, DME and other services for aftercare to ensure scheduling of the services and equipment prior to discharging from the facility. She said failing to follow up with services could result in the resident not having the aftercare and needed equipment to function at home. During an interview on 05/06/2025 at 2:42 PM with KR K revealed the hospital was discharging the resident home, since the family did not want a referral for services in a nursing home. She will consult with them to request more time before discharging the resident home. During an interview on 05/12025 at 840 AM with KR K she stated Resident # 1 was discharged home. She stated that the apartment has been cleaned, and she and KR C are visiting daily until HHS or other aftercare services were provided. KR K said the barrier to placement and services were limited insurance benefits. An Immediate Jeopardy (IJ) situation was identified on 05/08/2025 at 11:00 AM after an administrative review determined that the noncompliance would be elevated to an IJ. The ADM was provided an IJ template and told that the current POR (Plan of Removal) that was accepted on 04/26/2025 at 1:22 PM was sufficient. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The following Plan of Removal was accepted on 04/26/2025 at 1:22 PM for immediate actions to ensure residents were not in jeopardy of harm. The POR reflected the following: The Plan of Removal reflected the following: Plan of Removal - F 835 submits the following Plan of Removal for the alleged failure to develop an effective discharge planning process. By submitting this plan of removal covered the non-compliance. does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? 1. The following plan was implemented to ensure the discharge planning is effective immediately on 4/25/2025 for all upcoming discharges: a. Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided. b. Discharge paperwork will be presented to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. c. A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney. d. Post discharge services such as home health will be set up prior to discharge. e. Physicians and NP's will be notified of discharges to address resident's needs. f. Resident #1 no longer resides at the facility was at the hospital How were other residents at risk to be affected by this deficient practice identified? 1. All residents discharging from the facility have the potential to be affected by this alleged deficient practice. What does the facility need to change immediately to ensure that residents have a safe discharge from the facility and to ensure that this does not happen again? a. An in-service was completed on 4-11-25 with the Administrator by the Regional [NAME] President of Operations that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. b. An in-service was completed on 04/11/2025 with the Social Worker and Case Manager by the Administrator that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. c. An in-service was completed on 4/11/25 with the IDT by the Administrator regarding the completion of the discharge summary, notifying the Physicians and NP's of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. d. All discharges will be reviewed by the IDT in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed. e. All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/ or administrator will contact the ombudsmen and seek assistance if needed for guardianship. How will the system be monitored to ensure compliance? a. The DON/Designee will review all discharge orders for upcoming discharges for completion daily for the next week and three times a week for the following 6 weeks. b. The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs daily for the next week and three times a week for the next 6 weeks. c. The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health daily for the next week and three times a week for 6 weeks. Quality Assurance An impromptu (unplanned) Quality Assurance and Performance Improvement review of the removal plan will be completed on 4/25/25 with the Medical Director for agreement with this plan. Monitoring of the POR included: Record review of in-service training report dated 04/11/2025 by the RD with the ADM, time unknown, reflected Appropriate discharge planning include the following steps: Discharge summary completion, communication of discharge orders, confirmation of home health orders information of on discharge transportation, Notification of discharge to RP/POA and resident if cognitive. The ADM's signature was observed on page 2 confirming attendance. Record review of a facility in-service titled discharge date d 04/11/2025, time unknown, by the ADM, reflected to ensure appropriate discharge planning of residents and to ensure safe discharge time following items have been completed: 1. Family members of RP will be required to pick up residents. 2. We will no longer provide courtesy transportation. 3. RP will sign discharge. 4. Discharge will only be signed by a cognitive party/resident and or family member. Signatures of staff that participated in the in-service revealed CM T, LSW, MDS D, LVN M, RN H, RN G, LVN S, LVN R, LVN O, LVN A, LVN B. Record review of facility Inservice titled Discharge Plan of Care Completion UDA's department managers dated 04/2025 time unknown by ADM reflected Please ensure that the discharge plan of care UDA's (User defined assessments) are completed within 48 hours of discharge. Discharge summaries are to be completed within 48 hours of discharge. Ensure that the physician and NP assigned to the resident is notified of the upcoming discharge to address any additional resident needs. The facility will ensure that discharge paperwork will be signed by only cognitively intact residents and/or responsible party on power of attorney. Signatures of staff that participated in the in-service, CM T, LSW, ADON, LVN E, DON, LVN K, and MDS R. the date of the in-service was not dated at the top or bottom of the in-service. Record review of in-service titled dated April 25, 2025, by ADM for the dual services department/ social services titled discharge planning reflected to ensure residents safely discharge back their prior settings, Family members will be required to provide their own transportation. Family members will be required to sign discharge paperwork. Staff signatures LSW P and CM T. LSW and CM T signature was observed on page 2 confirming attendance. Record review on 04/26/2025 of Residents #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 were reviewed for residents with discharged planning completion from the facility on or after 04/08/2025. The charts indicated appropriate notifications were made and the resident's discharges were safe. Interviews were conducted on 04/26/2025 from 4:15 PM to 5:30 PM, with ADM, DON, ADON N, MDS R, LSW, CM T, RN G (1st shift), RN H (2nd shift), LVN S (2nd shift), LVN O (2nd shift), LVN L (1st shift), LVN J (1st shift) RN U (1st shift) regarding training on discharge planning for residents included: ensure that nursing/social services staff follow up with aftercare services and MD/PCP to confirm resident client service status; ensure who and where the resident will be living and if supervision was needed or left alone; ensure cognitively impaired residents are not transported via public transportation; ensure all assessments, care plan, and MDS are completed prior to discharging the resident, and ensure the NP and MD were notified prior to discharge of date, plan, and time of discharge in order to obtain additional services and approvals for the resident to discharge. The staff said that follow up calls would be conducted to confirm follow up appointments and services for aftercare. Ensure the POA/RP have the correct contact information of the pharmacy and MD/PCP are provided to pick up RX's and for the follow up appointment in two weeks; ensure the POA/RP have knowledge of the delivery timeframe for DME and expectations of billing; ensure the resident's POA/RP were present at discharge to transport from the facility. In an interview with the ADM and DON on 04/26/2025 at 5:48 PM, both stated that ongoing monitoring and auditing by the IDT, DON, ADON, and LSW will completed for accuracy of resident assessments, discharge planning, discharge summary's, resident cognitive and functional abilities, referral and notification of resident's after care services, follow up calls to after care service providers within 24 to 48 hours to ensure residents service implementation and resident safety. Record review of the facility policy untitled and undated reflected in part Policy Statement.: A licensed Administrator is responsible for the day-to-day functions of the facility Policy interpretation and implementation: he is governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility .Ensuring that each resident's right to fair and equitable treatment, self. determination, individuality, privacy, confidentiality of information, property, and civil rights, including the right to lodge a complaint, are strictly enforced .Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities. Delegation of authority/chain of command: In the absence of the Administrator, the Assistant Administrator or Director of Nursing Services is authorized to act in the Administrator's behalf. Should both the Administrator and the Assistant Administrator or Director of Nursing Services be absent, the chain of command as established by this facility shall be followed. A complete outline of the Administrator's duties and responsibilities is contained in his/her job description. The Administrator was informed the Immediate Jeopardy was removed on 05/26/2025 at 5:45 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for pain management. The facility failed to adequately assess and treat Resident #1's severe breakthrough pain as he was screaming in unrelenting pain. The noncompliance was identified as past noncompliance. The Immediate Jeopardy was identified on 02/05/25 at 1:02 PM and was removed on 02/05/25 at 4:15 PM. The facility corrected the noncompliance before the investigation began on 02/04/25. The Immediate Jeopardy occurred in the past and the facility had already corrected the non-compliance. This failure could place residents at risk for unnecessary pain, discomfort and a decreased quality of life. Findings included: Record review of Resident #1's electronic face sheet, dated 02/04/25, reflected a [AGE] year-old male, who admitted to the facility initially on 06/15/22, and had a readmission date of 01/31/25. Resident #1 had a diagnosis of Type 2 Diabetes (body does not use insulin effectively or does not produce enough insulin), Essential Hypertension (high blood pressure), Dementia (decline in mental abilities), Heart Failure, and History of Falling. Record review of Resident #1's care plan, dated 06/29/22 was the only care plan listed for the resident from a previous admission. The past care plan did reflect a history of pain due to a past pelvic fracture. The care plan reflected the goal was for Resident #1 to remain free from pain or at a level of discomfort acceptable to the resident. The care plan also reflected a goal of decreased pain within one hour of intervention. The interventions listed on the care plan for pain were to administer pain medications per the physician's orders, given PRN medications for breakthrough as per the physician's orders, note effectiveness, and to report complaints and non-verbal signs. Record review of Resident #1's electronic record reflected no documented pain assessments on 1/31/25 or 02/01/25. Record review of Resident #1's physician's orders dated 02/04/25, reflected the following: Tramadol HCl Tablet 50 MG Give one tablet by mouth every four hours as needed for moderate and severe pain, order date 02/01/25 Tylenol 8-hour Arthritis Pain oral tablet extended release 650 MG (Acetaminophen) Give 1 tablet by mouth three times a day for pain, order date 02/01/25 Monitor pain every shift, order date 01/31/25 Record review of Resident #1's Nurse Administration Record, dated [DATE], reflected the following: Monitor pain every shift, with a start date of 02/01/25 and an end date of 02/03/25. Record review of the progress notes on Resident #1's electronic record, dated 02/04/25, reflected the following: 02/01/25 18:17 (6:17 PM) Note Text : late entry: patient was found on floor of room, patient had no skin tears, bp 186/90 p100, patient expressed pain through with consistent yelling ow and help me he also kept grabbing his right hip and refused to lay on that side when being assessed. NP D and DON [DON] were notified as well. wife stated patient can take 650mg tylenol for relief. this nurse administered the 650mg tylenol and patient showed relief. NP [NP D] ordered full pelvic xray. [DON] ordered tramadol and tylenol. this nursehas entered orders. patient is in need of a sitter due to his urge to wander to prevent falls, bed has been in low position since admission on [DATE]. plan of care ongoing. Author: [LVN A] 02/01/25 21:15 (9:15 PM) While waiting for the X-ray results, the family requested the resident be sent to the emergency room due to pain. A 911 call made, EMS arrived and transport the resident to [Hospital name]. RP is present, and the administration notified. Author: [ LVN B] Record review of Resident #1's hospital document dated 02/04/25, reflected Resident #1 was diagnosed with a right hip fracture that required surgery. In an interview on 02/04/25 at 11:10 AM, NP C stated the facility called her, and let her know Resident #1 was in pain, but did not mention he had a fall. She stated right after the call, she sent the order for tramadol on 02/01/25 at 11:30 AM to the facility staff. In a telephone interview on 02/04/25 at 12:37 PM, Resident #1' Family Member confirmed that Resident #1 had a hip fracture and had surgery the morning of 02/04/25. The Family Member stated they arrived at the facility around 9:50 AM on 02/01/25, and the fall must have occurred before then. The Family Member stated Resident #1 was screaming and yelling in pain when they arrived at the facility to visit. The Family Member stated no one was going into Resident #1's room to assist him. The Family Member stated they requested to speak with the DON, but the DON was not there. The Family Member stated the MOD came into the room to talk to them around 10:30-11:00 AM. The MOD informed her that pain medication and x-rays were requested. In an interview with the DON, on 02/04/25 at 12:57 PM, the DON stated Resident #1 fell on [DATE]. The DON stated it was an unwitnessed fall. She stated LVN A heard Resident #1 yell, and went in to see him on the floor. The DON stated during the admission, the day before, the Family Member of Resident #1 informed the facility that Resident #1 was a little impulsive and moved around often. The DON stated the facility put interventions in place like the bed at the lowest level and placed two fall mats around his bed. The DON stated she was not sure exactly what time the fall occurred, but LVN A sent her a text message around 9:26 AM about Resident #1's fall. The DON stated LVN A contacted NP D and requested x-rays around the same time. The DON stated at 11:26 AM, she spoke with NP D, and NP D informed her she was out of the country, but she was able to provide an order for the x-rays. The DON stated NP D told her to contact NP C to get the order for pain medication. The DON stated by 11:30 AM, the facility had received the order for the Arthritis Tylenol and the Tramadol. The DON stated she was not sure if Resident #1 had any pain medications between 9:00 AM and 11:30 AM. She stated Resident #1 did not admit to the facility the day before with any pain medication. The DON stated the staff at the facility were immediately in-serviced starting on 02/02/25 regarding pain management, notification of changes, documentation, resident rights, and abuse and neglect. She stated they started reviewing all resident files and medication records to check for any additional concerns. In an interview on 02/04/25 at 1:26 PM, the MOD stated she was the manager during that weekend when Resident #1 had the incident. She stated she arrived at the facility around 10:20 AM, made her rounds on the other side of the facility, then made her way to the side where Resident #1's room was, around 11:00 AM or 11:15 AM on 02/01/5. The MOD stated LVN A did not tell her about any incident with Resident #1, but the resident's Family Member was present in the room and informed her that Resident #1 was in pain. She stated she asked the Family Member had Resident #1 received any medication for pain, and the Family Member stated they were not aware of any pain medication given to Resident #1. The MOD stated Resident #1 was laying on his back and did appear to be in pain. The MOD stated she went to his nurse, who was LVN A, and LVN A stated she gave him some pain medication about 30 minutes ago. She stated LVN A stated she had contacted NP D for pain medication, and wife told her he could take Tylenol. The MOD stated after speaking with LVN A, she contacted the DON, because the DON can get orders quicker than the nurses at times. The MOD stated x-rays sometimes took longer on the weekend. She stated she did not check back with the resident or LVN A, because she had not heard anything else about the incident before she left work. The MOD stated they did start in-services on Sunday 02/02/25. She stated she received an in-service on abuse and neglect, pain management, resident rights, notify of changes, documentation, and incidents. The MOD stated she was informed to contact the DON or an ADON immediately if there were concerns with anything at the facility regarding pain management. In a telephone interview on 02/04/25 at 2:05 PM, NP D stated LVN A contacted her around 10:42 AM after the fall happened. She stated LVN A told her he had a fall and was screaming in pain. NP D stated she told LVN A to get x-rays, and LVN A told her Resident #1 had a hip injury in the past and it was normal for him to be in a little pain. She stated she had to repeat to the nurse to get the x-ray. NP D stated she did not receive the x-ray results until the next day. She stated she was informed LVN A was fairly new and called the wrong x-ray company, so it took a little longer than normal. In a follow-up interview on 02/04/25 at 2:20 PM, the DON confirmed LVN A contacted another x-ray company that the facility didn't normally use, so it did take longer to get the results. The DON stated she did not see on the MAR where the Tramadol was given to Resident #1, but she would research a little more. She stated Resident #1 did get Tylenol. She stated she was unsure of what time Resident #1 received Tylenol that morning, because LVN A did not mark the Tylenol as given on the MAR. The DON stated LVN A did leave a progress note around 1:30 PM, stating she administered Tylenol earlier that day. In a telephone interview on 02/04/25 at 3:07 PM, Medication Assistant E stated he was the one that administered the Tylenol to Resident #1 around 2 something in the afternoon on 02/01/25. He stated he remembered giving him the Tylenol, because he crushed his medications. He stated he was not able to swallow pills. He stated no one was present in the room other than he and Resident #1. He stated he did see Resident #1's family member in the facility. Medication Assistant A stated he was told by staff that Resident #1 did fall. He stated Resident #1 kept telling him he was in pain. He stated if Resident #1 had an order for Tramadol, he would not be the staff member to administer that medication. He stated LVN A would have been the one to administer Tramadol. Medication Assistant E stated he was present at the facility when Resident #1 was transported to hospital, but he could not remember what time. He stated it was before he left work, and he left work around 10:00 PM. A telephone interview was attempted with LVN B on 02/04/25 at 3:15 PM, but there was no answer. In a telephone interview on 02/04/25 at 3:22 PM, LVN A stated she no longer was working at the facility. She stated she already told everyone what happened. LVN A stated Resident #1 had an unwitnessed fall around breakfast time on 02/01/25. She stated she did not remember the exact time of the fall. She stated she immediately contacted NP D, who gave her orders for x-rays. She stated she had to put the x-ray order into the system to request the x-ray company to come to the facility. LVN A stated the x-ray company arrived at the facility around 5:00 PM that evening, on 02/01/25. She stated she believed she received an order for pain medication around mid-day but did not recall the time. LVN A stated all she knew was Resident #1 received a dose of Tylenol, but she did not remember the time she administered it. She stated she crushed it and put it in applesauce, because the resident was on a pureed diet. LVN A stated Resident #1 did not yell as much after he received the Tylenol. She stated she did not complete the pain assessments or neuro checks, because Resident #1 was not yelling as much as he was that morning. LVN A stated the Tramadol never arrived. She stated she was in-serviced on pain management and fired. LVN A stated that was all she was going to say about the incident and hung up the telephone. On 02/04/25 at 3:55 PM, Surveyor and the ADON reviewed the medication cart, and Resident #1 did not have any Tramadol on the medication cart. The over-the-counter Tylenol was on the medication cart. The ADON stated she would contact the pharmacy to see if the Tramadol was taken from the e-kit. On 02/04/25 at 5:13 PM, via email, the DON stated the Tramadol was never delivered on 02/01/25, because the pharmacy noticed Resident #1 was sent to the hospital. She stated the Tramadol was never pulled from the e-kit either. In an interview on 02/05/25 at 10:03 AM, the Weekend Supervisor RN stated she was aware of the incident with Resident #1 and LVN A. She stated she arrived to work that Saturday, 02/01/25 around 8 something that morning. The Weekend Supervisor RN stated the DON asked her to go check on LVN A around 10:00 AM. She stated the DON stated LVN A may need some help. The Weekend Supervisor RN stated the DON told her LVN A said Resident #1 was demented, that LVN A wanted to send him out to the hospital, and that LVN A felt that Resident #1 was not appropriate for the facility. The Weekend Supervisor RN stated she went to check on LVN A and she stated she could hear Resident #1 screaming. The Weekend Supervisor RN stated LVN A told her he had been screaming all morning. She stated she asked LVN A what was wrong with him, and she told her he had a fall. The Weekend Supervisor RN stated LVN A told her his bed was at the lowest level when he fell on the fall mat. The Weekend Supervisor RN stated she asked if he was given any medication for pain, and LVN A stated he did not have any medication on his chart for pain. The Weekend Supervisor RN stated she did not believe LVN A told the DON that resident had a current fall but just that he had a past hip injury. She stated LVN A told her she had already contacted the nurse practitioner and had requested x-rays. She stated Resident #1's family was at the facility that day, and they had not complained anymore about the pain. She stated she didn't hear him screaming anymore, so she did not know there was still an issue with pain management. The Weekend Supervisor RN stated after the incident, the following day, the staff received in-services on abuse and neglect, pain management, documentation, resident rights, incidents, and notifying the appropriate people. She stated she was informed to contact the DON if there were any future issues with pain management. The Weekend Supervisor RN stated the risk of not following up on pain management is that Resident #1 would continue to be in pain and also the quality of care. In a follow-up interview on 02/05/25 at 10:43 AM, the DON stated LVN A called her around 9:30 AM on 02/01/25, told her that Resident #1 fell. She stated she told LVN A to do an incident report, follow through with the pain assessments, to notify the family and doctor, and asked if pain medications were on board. The DON stated she initially told LVN A to contact NP D, but she also contacted NP D. The DON stated NP D told her to contact NP C for the pain medication. She stated she received the order for x-ray and pain medication and forwarded those orders to LVN A at 11:32 AM on 02/01/25. She stated she was unaware on 02/01/25 that the pain medication, Tramadol, was not received. The DON stated LVN A should have followed through with completing pain assessments throughout the shift. She stated the pharmacy the facility used was in Sulphur Springs, Texas (about 95 miles away). The DON stated the pharmacy had two drop times: 2:00 PM and midnight. She stated LVN A did not follow up with the pharmacy about the Tramadol. She stated if she was aware the Tramadol had not arrived, she could have gotten it from the e-kit. The DON stated the risk of LVN A not following through with pain management or sending the resident to the hospital sooner was Resident #1 might have suffered longer. In an interview on 02/05/25 at 11:08 AM, the Administrator stated LVN A and the Weekend Supervisor RN were responsible for following up on the pain assessments and pain management for Resident #1. She stated there should have been an initiative to get the Tramadol from the e-kit when Resident #1 was still complaining of pain. She stated LVN A should have completed pain asessments throughout the shift. The Administrator stated she felt there was not really a risk since Resident #1 did receive the Tylenol. The Administrator stated after the incident, starting on 02/02/25, the facility completed in-services on abuse and neglect, pain management, incidents, incident reporting, resident rights, notification of changes, pain assessments, and documentation. The Administrator stated on 02/02/25, the DON started an audit to ensure all nurses complete pain assessments, incident reports, and neuro checks. The Administrator stated she has reviewed and will continue to review and verify during the morning stand up meetings Monday through Friday. The Administrator stated on the weekend, she, the DON, and the weekend supervisors would monitor and review. She stated with pain management, the DON and the ADONs have started doing audits with new admissions as well as current residents. She stated they started a checklist to ensure orders are in place, the DON has started a report on medications ordered. The Administrator stated the DON started daily audits, and she has weekly audits. The administrator stated the DON and ADONs have started monitoring all changes in condition and the managers review during the daily stand-up meeting. The Administrator stated on the weekends, the DON and ADONs would do check-ins. She stated mass text messages were sent to the nurse staff to contact the DON or ADONs on the weekend concerning pain management. An Immediate Jeopardy for past non-compliance was identified on 02/05/25. The Administrator was notified of the Immediate Jeopardy for past non-compliance on 02/05/25 at 1:02 PM and were provided with the Immediate Jeopardy Template. The facility was not asked to provide a Plan of Removal, since the Immediate Jeopardy occurred in the past and the facility had already corrected the non-compliance. Record review of a document titled, Emergency Plan of Correction dated 02/03/25, reflected the following: Emergency Plan of Correction Risk Management/ Pain Management 2/3/2025 Problem: Timely Incident Reporting/ Timely Incident Accident Documentation Initiation/ Pain Management Immediate Action: All Nursing Staff ln-service, scrubbed risk management documentation, and mass text to notify all staff to call DON and Administrator of any incident/accident immediately Date Completed: 2/2/25 Systemic: DON, ADON, and Administrator will promptly assess documentation for MD and family notification. And assess orders for need for pain regimen and management. Date Completed:2 2/2/25 - ongoing. Monitoring: Daily monitoring of risk management tab and pain assessment. In an interview on 02/05/25 at 1:56 PM, Caregiver G stated she received in-services on abuse and neglect, resident rights, pain management, notifying a nurse or management if a resident complains about pain, documentation, incident reporting, and fall prevention within the last two days. She stated she was trained to let a nurse know if a resident had an accident or if the resident was in pain. She states she was in-serviced on following up to ensure the nurse checked on the resident. She stated if that resident still complained of pain, she would let the DON know. In an interview on 02/05/25 at 2:11 PM, Medication Assistant H stated she was in-serviced on Monday about abuse and neglect, resident rights, pain management, incident reports, documentation, notifying nurses of incidents, and fall prevention. She stated she was in-serviced about letting a nurse know if a resident was in pain, so the nurses could do pain assessments. She stated she could provide pain medication if it was available and if the resident had not already had pain medications. She stated some medications have to be given by the nurse. In an interview on 02/05/25 at 2:24 PM, RN I stated she worked on the weekend, and she received in-services then. She stated the in-service were over pain management, pain assessments, neuro checks, incident reports, documentation, notification of changes, resident rights, and abuse and neglect. She stated if there was any time of pain management with a resident, all nurses were to follow-up with management. In an interview on 02/05/25 at 2:33 PM, LVN J stated he received in-services this week over abuse and neglect, pain management, fall prevention, documentation, assessments, checks, and notifying the families and the physician. He stated he was told to update the DON with any pain management concerns. He stated he was informed if he worked on the weekends to follow up with the weekend supervisor, ADON, or DON with concerning pain management. In an interview on 02/05/25 at 2:43 PM, ADON F stated she received in-services on Monday regarding pain management, abuse and neglect, resident rights, documentation, fall prevention, chain of command, notification of changes, incidents, and accidents. She stated when there is an incident like a fall, the pain assessments, neuro checks, incident reports, and overall documentation should be available in their electronic system. Record review of a document titled, Record of Disciplinary Measure, dated 02/02/25, reflected LVN A was disciplined and terminated for resident abuse, neglect, or failure to report such incidents immediately and failure to follow facility rules, policies, and procedures. The document reflected LVN A had a patient under her care who had a fall on 02/01/25 and nurse failed to complete neuro checks/assessments and to monitor Resident #1 after the fall. Record review of an in-service titled, Abuse and Neglect dated 02/02/25, and covered the facility's abuse and neglect policy. All care staff on the employee roster received the in-service. Record review of an in-service titled, incident/accident/neuro checks dated, 02/02/25, and covered accident, incidents, chain of command, and documentation. All care staff on the employee roster received the in-service. Record review of an in-service titled, Nurses Falls Witnessed and Unwitnessed, dated 02/02/25, and noted it covered, falls, incidents, pain management, medication orders, x-rays, sending residents out to the hospital, and notifying management, including the DON, as well as the doctor and the family. All care staff on the employee roster received the in-service. Record review of the facility's policy titled, Pain Management, dated 2001, with a revision date of April 2009, reflected the following: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain. b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. Recognizing Pain: I. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body;