**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged while the appeal was pending for 1 of 5 residents (Resident #1) reviewed for discharges, in that: The facility failed to have a valid reason to discharge Resident #1 and failed to permit Resident #1 to remain in the facility while her discharge appeal was pending. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/22/23 at 5:01 p.m. While the IJ was removed on 9/24/23 at 7:06 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were discharged safely. This failure could result in residents being discharged without appropriate reasons and could place a medically compromised resident at risk of a decline due to changing clinical environments and care continuity. The findings were: Record review of Resident #1's diagnoses page, dated 9/20/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with hyperglycemia [high sugar levels in the blood], hypothyroidism [when the thyroid does not produce enough hormones], essential (primary) hypertension, and unspecified vision loss. Record review of Resident #1's admission documents, dated 12/13/22 revealed no mention of a behavioral contract. Record review of Resident #1's care plan, dated 1/19/23, revealed the following focus area: Resident uses profanity towards staff during care or when staff is rounding every 2 hours. Resident yells at staff. This focus area has the following interventions: - Ask yes/no questions in order to determine the resident's needs. - Engage the resident in simple, structured activities that avoid overly demanding tasks. Determine activities of interest and adapt these to current attention/cognitive level. Record review of Resident #1's quarterly MDS, dated [DATE], Section Q revealed the following items: - Q0400: Discharge Plan A. Is active discharge planning already occurring for the resident to return to the community? The answer to this item was No. - Q0500. Return to Community. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond): Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The answer to this item was Unknown or uncertain. Record review of the all of the facility's electronic incident reports revealed no incident of any physical abuse involving Resident #1. Record review of a document titled, NOTICE OF PROPOSED TRANSFER/DISCHARGE, dated 8/16/23, revealed Resident #1 was given a 30-day discharge notice on 8/16/23 with a discharge date of 9/16/23. The reasons for discharge were list as: Resident refuses MD in facility . Refuses services to include mistreatment of staff to include profanity and belittling staff . Resident has failed . to pay or refused to pay for stay at the Facility AND the resident has not submitted the necessary paperwork for third party payment . If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal . The facility will not discharge/transfer you while the appeal of your discharge/transfer is pending if you exercise your right to appeal unless the failure to discharge/transfer you would endanger your health and safety or that of other residents/other individuals in the Facility. On the signature line was no signature from Resident #1, CO E, or CO F on this discharge notice. Instead, there were the words, Copy handed to [CO E], written by DON J. Record review of a facility document titled, Appendix B. Patient/Family Behavior Contract, dated 8/16/23, revealed the following: Behavior Expectations: 1. Will not belittle staff while discharge is pending [DATE]. 2. Will not use profanity while discharge is pending [DATE]. Will allow [the facility's physician group] to provide care while discharge is pending [DATE]. There was a section below this that read: I have read and understood the above-listed behavioral expectations. I also understand that failure to meet these expectations may result in immediate termination of the relationship between me and the provider/organization. This section had a portion for the resident or responsible party to initial and there was no initial present. At the bottom of this same document there was no signature from Resident #1, CO E, or CO F. There was a signature from the Administrator and DON J as well as the words, Family refuses to sign 8/16/23. Next to these words were the Administrator's initials. Record review of Resident #1's BIMS assessment, dated 8/17/23, revealed Resident #1 had a BIMS score of 15, signifying no cognitive impairment. Record review of a document titled, Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Nursing Facility Discharge, dated 9/15/23, revealed CO F signed for an appeal of Resident #1's discharge on [DATE], before the projected discharge date on Resident #1's 30 day discharge. Record review of a group text message between the Administrator, DON I, and the Director of Activities and Life Enrichment, dated 9/18/23 at 8:53 p.m., revealed the following message from the Administrator to this group: I spoke with [ADON L.] Apparently last week [Resident #1] was so rude to [a CNA] that nurses had to intervene and nurses had to provide care . [ADON L] wants us to evict [Resident #1] based on violating the behavior policy . 1. If we go to appeals court, we have no way to win. They do not evict for behavior. 2. We evict for violation of behavior contract we may get a tag for dumping. DON I responded to the Administrator's message with the following: I agree that abuse at work is hard and if there is any path to cultivating a safe and peaceful work environment, we should take it. I vote for an eviction and amendment to prevent future abuse from residents. Record review of Resident #1's nursing progress notes from 8/15/23 to 9/19/23, obtained 9/21/23, revealed the following: - Nursing progress note, dated 9/19/23 at 2:20 p.m. and written by ADON L: Pt was discharged to her home with [CO E]. Pt was discharged with all medications and instructions/directions for administration. Glucometer [a machine to check blood sugars], strips, and syringes also provided. Pt provided with wheelchair and her personal walker for short distances as sheis [sic] ambulatory. Further record review of the progress notes from 8/15/23 to 9/19/23 revealed was no documentation indicating Resident #1 was physically or verbally aggressive to staff members or other residents. However, there was documentation Resident #1 occasionally refused blood sugar checks. Record review of a text message between the Administrator and the Ombudsman, dated 9/19/23 at 2:41 p.m., revealed the following message from the Administrator to the Ombudsman: I'm sorry we evicted [Resident #1] based on the abusive behavior to the staff and took her to [CO E's] house. Record review of the Administrator's statement titled, Ms. [Resident #1], not dated, revealed the following: [Resident #1] has been unkind and demanding from the beginning . She purposefully slowed all the staff down . she demanded her meals be a certain way, and then change the way repeatedly . She demanded showers lasting 45min - 1hr; bathroom time 30 min - 45 min. Many times managers or nurses would have to jump in and help to free up staff. She demeaned, belittled, verbally attacked front line staff (CNAs) calling them names, questioning their intelligence, their skills, etc. She was especially vicious to African American staff. Many times management had staff in their offices crying, threatening to quit, begging to be reassigned . [Resident #1] refused to allow us to file for Social Security, which means no payment for [the facility], no Medicaid. So we have been providing free care. We have tried to educate, plead, involve the family, and finally 2 months ago [Resident #1] agreed . When I returned from [a local] Conference, I found another staff had left [Resident #1's] room crying and the ADON had to intervene and nurses had to provide care. I evicted her on the basis of the behavior contract. During an interview on 9/20/23 at 11:16 a.m., the Ombudsman stated on 8/16/23 she attended a care plan meeting wherein the facility presented Resident #1 and [CO E] with a behavioral contract which detailed that if Resident #1 continued to verbally abuse staff, then Resident #1 would be discharged . The Ombudsman stated after the facility presented the behavioral contract, the facility then issued a 30-day discharge. The Ombudsman stated, from what I can tell it wasn't curse words. It was just her questioning the validity of the staff. They were having an issue with [Resident #1] seeing anyone [a physician] in the facility and that she wouldn't choose her own doctor. They were also saying that [Resident #1's] medication was going to run out . I filed the appeal [for Resident #1] this past Friday [9/15/23], I called this past Monday [9/18/23] and told [the Administrator] the appeal had been filed. The Ombudsman stated since the meeting on 8/16/23, Resident #1 agreed to see the facility's physician. During an interview on 9/20/23 at 3:39 p.m., Agency LVN K stated she worked with Resident #1 and worked on 9/19/23. Agency LVN K stated she did not know anything about Resident #1's discharge on [DATE] because Resident #1's discharge occurred before her shift from 2:00 pm to 10:00 p.m. Agency LVN K stated Resident #1 was blind and needed assistance with transfers and needed assistance with walking to and from the bathroom to her [Resident #1's] bed. When asked if Resident #1 was ever aggressive, Agency LVN K stated Resident #1 was never physically aggressive to her [Agency LVN K], but was verbally aggressive to CNAs. Agency LVN K stated Resident #1 would often yell when Resident #1 felt things were not done fast enough and would often swear at CNAs or talk down to the CNAs. During an interview on 9/20/23 at 4:52 p.m., ADON L stated she had only been with this facility for about one month. ADON L stated, my understanding of a discharge is that you're going to get some discharge orders and understand if the patient is going to the hospital or another facility or home and try to set up a smooth discharge so it's a safe transfer to wherever the patient is electing to discharge by helping them set up any follow-up appointments if they need to or DMEs if they need that or hospice. It just depends on what the discharge entails. When asked how did the discharge planning process start and how did the discharge planning progress, ADON L stated, I don't have too much input [in the discharge planning process.] I haven't been phased that much in decision-making or keeping up with the status as of yet. The ADON stated the Administrator and other staff members, like the Admissions Staff, were also involved in the discharge, but the Administrator spearheads the admissions and discharges. When asked how the facility involved a resident in the discharge, ADON L stated, families will be contacted and asked to come in and have a meeting and at the meeting is where the discussion will happen, how to better meet [the resident's] needs . It's important to have the family or the love one involved. So we try to get as much input as possible. When asked what the facility's policies stated about facility-initiated discharges, ADON L stated, I'm not able to tell you off the top off my head. ADON L stated Resident #1 was diabetic, blind, petite, and wanted things done in a particular fashion. ADON L stated, [Resident #1] kind of demands more of your time. You're unable to provide care to other residents because for something as small as [Resident #1 wanting] to wash [her] hands . It's hard to anticipate what she wants . And if you don't get it right, she'll insult you. During an observation and interview on 9/21/23 at 8:10 a.m., Resident #1 was observed lying in bed in a local hospital. Resident #1 stated she wanted to stay in the facility. Resident #1 stated, I didn't know I was going to be discharged . I'm still shaking from it. It was awful. Resident #1 stated around 2:00 p.m., CNA A told her someone was coming to work in her room so they had to get her out. Resident #1 stated, and before I knew it [CNA A] was taking me out of the room in a rush . They put me in a wheelchair and rushed me out I got to [CO E's] house . they pushed me up on the wheelchair on that porch. When asked about her behaviors, Resident #1 stated, [The Administrator] said I was cruel to the nurses.Maybe I shouted one time. Resident #1 stated she was not physically aggressive to other residents or staff. When asked what was explained to her [Resident #1] about her behavior contract, Resident #1 stated, I don't know. When asked what the facility told her about any consequences of the behavior contract, Resident #1 stated, Just that I would be discharged . Resident #1 stated, [The Ombudsman] was helping me with an appeal . I remember 9/15/23 was the discharge date . And [CO E] said she called [the Ombudsman] to file an appeal. That was 9/11/23. I wasn't expecting them to discharge me. Resident #1 stated she never refused to see the facility's physicians and stated she saw Physician D on 9/15/23. During an interview on 9/21/23 at 10:47 a.m., LVN B stated Resident #1 tended to take a lot of time to do activities of daily living such as bathing and washing her hands. LVN B stated it would typically take 20-25 minutes. LVN B stated, it takes up too much time as far as doing that.They said she's refused stuff as far as not letting her blood sugar checked. When asked if Resident #1's needs were beyond what she could provide, LVN B stated, no, it just takes time. LVN B stated Resident #1 was not verbally aggressive with her, but was aware Resident #1 was verbally aggressive with some CNAs. LVN B stated, I don't know if she was physically aggressive. I just know she was just verbally inappropriate. I've heard she's racist . As far as being mean, she could be sarcastic with words, like call people stupid. LVN B stated she did not feel unsafe working with Resident #1. When asked if she knew if any of her co-workers felt unsafe working with Resident #1, LVN B stated, I don't think physically, but sometimes I think the fear is that they [the co-workers] might lose their job. LVN B stated she worked on 9/19/23 and towards the end of her shift (at around 2:00 p.m.) ADON L told her [LVN B] that she [ADON L] needed Resident #1's medication because Resident #1 was going home. LVN B stated from ADON L was in charge of Resident #1's discharge. During an interview on 9/21/23 at 11:13 a.m. HA C stated she took care of Resident #1. HA C stated Resident #1 likes to have things a certain way . She was very snappy. She does have her moments where she got mad at us for certain stuff, but it was normal resident stuff. And not being on time for her insulin one was one of them. When asked if she ever felt unsafe with Resident #1, HA C stated, No, she just uses her words a little bit much. When asked if she knew if any of her other co-workers felt unsafe with Resident #1, HA C stated, No. HA C stated she worked on 9/19/23, but did not know anything about Resident #1's discharge that day. During an interview on 9/21/23 at 11:40 p.m., CNA A stated, [Resident #1] was very demanding woman. She'll talk to you, but she'll talk down to you because she doesn't figure you're on the same level as her. CNA A stated the other CNAs reported Resident #1 was mean. CNA A stated, her yelling, and her particularness and it makes you feel bad, especially if you're new or an agency [staff]. CNA A stated he never felt unsafe working with Resident #1. In a follow-up interview on 9/21/23 at 12:09 p.m., ADON L stated Resident #1 would refuse blood sugar checks and insulin, would make accusations, and was verbally abusive. ADON L stated she never witnessed the behavior herself. ADON L stated, it was not anything beyond what the staff could provide, it was just the time it took to complete the task. ADON L stated Resident #1 was discharged because of her behaviors. ADON L stated on 8/16/23, Resident #1 was placed on a behavior contract. ADON L stated, The meeting was for the notice of proposed transfer or discharge due to her behaviors. For this situation, [Resident #1] had 3 stipulations. Her expectations were to not belittle staff while discharging on 9/16/23, will not use profanity, and will allow [the local physician group] to provide care until discharging . The failure to meet the expectation would be termination of the relationship between the patient and the provider. ADON L stated Resident #1 did begin to see the facility's physician group. ADON L stated she could not find a facility policy on behavioral contracts. ADON L stated she was not sure if the Ombudsman appealed Resident #1's discharge. ADON L stated if a resident's discharge was being appealed, she would wait to discharge until the hearing. ADON L stated the administrator initiated Resident #1's discharge on Monday, 9/18/23. ADON L stated, I think there were some complaints that may have happened on the weekend or Monday. ADON L stated Resident #1 wanted to stay in the facility. ADON L stated on Tuesday, 9/19/23, the Administrator told her [ADON L] Resident #1 was being discharged . ADON L stated at around 2:00 p.m. she then went to gather Resident #1's medications and prepare documentation for the discharge. ADON L stated shortly after 2:00 p.m., Resident #1 was placed in a wheelchair, taken to the facility van, and then driven to CO E's house. ADON L stated she was one of the staff members who were with Resident #1 during the journey. ADON L stated upon arrival, CO E closed the door and would not allow the staff to enter the home. ADON L stated CO E stated she [CO E] was going to call the police. ADON L stated Resident #1 transferred herself to the steps of the concrete porch and sat there. ADON L stated CO E did not open the door and she, along with the rest of the facility staff, left. During an interview and record review on 9/22/23 at 8:47 a.m., the Administrator provided her statement which was titled, Ms. [Resident #1]. The Administrator stated, Typically, I wouldn't play a role in the discharge, other than I sign off saying I know they went out. The Administrator stated if a resident was going to be discharged home, they would work with the family and speak with the family about the ramifications of not being in a nursing home. When asked when a resident was able to be discharged , the Administrator stated, Anytime the family wants them [the resident] to leave. Anytime they [the resident] needs skilled care because we can't provide care for them or meet their needs. For the appeals process, if they're [the resident is] not financially meeting their obligation, I think there's an avenue for that. When asked to explain the appeals process, the Administrator stated, years ago, we had a resident that we loved but the family was terribly frightening. And I talked to the president of the [facility's] board and he sent me to a lawyer in [another city] and she [the lawyer] said that you can give a 30-day eviction notice and they [the resident] can appeal, but the only way an appeal committee would hold it up is if they're [the resident is] not paying their bill. Failing to meet financial obligation. But I've never done an eviction, so I've never done an appeals hearing. When asked if a resident was able to appeal the discharge on ce a 30-day discharge notice was issued, the Administrator stated, Yes, absolutely. When asked what the facility's policy stated on facility-initiated discharges, the Administrator began to read the following from the facility's policy: transfer or discharge in which the resident objects to . is not in alignment for a resident's stated goals or preferences. A resident's declination of treatment is not grounds for discharge unless the facility is unable to meet the needs of the resident or protect the health and safety of others. The Administrator stated, We've never done that [a behavior contract] before and we have no policy on it. [DON J] had experience with that from a previous facility, so she was in charge of the behavior contract. We relied on [DON J's] experience from previous facilities. And [the Medical Records Staff] and [ADON L's] experience from other facilities, so I relied on the nurse . I'm sure they're [the behavioral contracts] are issued to put a family into notice that the behavior cannot continue. That we need those behaviors corrected in order to be here [in the facility.] Continuing the Administrator's interview on 9/22/23 at 8:47 a.m., the Administrator stated Resident #1 wanted to stay in the facility. When asked why Resident #1 was discharged , the Administrator stated Resident #1 was abusive to the staff. The Administrator stated Resident #1 made staff cry and threaten to quit. The Administrator stated during the care plan meeting on 8/16/23, they presented the behavior contract to Resident #1 and the family. The Administrator stated the consequence of the behavioral contract was immediate discharge if Resident #1 did three things: belittling of staff, using profanity, and now allow [the local physician group] to provide care. The Administrator stated the facility had assisted Resident #1 to apply for Medicaid. The Administrator stated DON I initiated the discharge. The Administrator stated on 9/18/23 the Ombudsman told her Resident #1's family had signed the appeal to the discharge. The Administrator stated the decision to discharge Resident #1 was made on the evening of 9/18/23 because Resident #1 did not adhere to her behavioral contract. The Administrator stated, it was so bad what [Resident #1] did to the staff and [Resident #1 was] calling them 'sasquatch' and 'stupid' and she would slow her words down and say, 'this is what I want, can you understand my words now?' So I gave up waiting on the appeals process because it was so egregious . she was escalating, being so mean to the CNAs that the nurses had to step in and provide care. The Administrator stated they placed Resident #1 in a wheelchair, placed her in the facility van, and then took Resident #1 to CO E's house. The Administrator stated because CO E did not open the door for the facility staff, they could not enter the home. The Administrator stated Resident #1 transferred herself from the wheelchair to the concrete porch and the facility left Resident #1 on CO E's porch. During an interview and record review on 9/22/23 at 3:40 p.m., DON I stated she had only worked in the facility for 12 days. DON I stated she was not involved with Resident #1's discharge and did not know Resident #1's discharge goals. DON I stated she was not aware of a plan to discharge Resident #1 on 9/19/23. DON I's message to the Administrator on the evening of 9/18/23 at 8:53 p.m. was reviewed with DON I. DON I stated she recalled the statement she made in response to the Administrator's message on 9/18/23. DON I stated her response to the Administrator's message was meant to be a generic response. DON I stated If someone was saying they were being abused, in very generic terms, that is not acceptable. During an interview on 9/23/23 at 3:11 p.m., DON J stated she worked at the facility from 1/20/23 until about July or August 2023. DON J stated she recalled Resident #1 and stated Resident #1 was supposed to be a long-term resident. DON J stated by the time she left, the facility was still looking for another facility for Resident #1. When asked if she would have dropped off Resident #1 on CO E's porch with her [Resident #1's] medications and paperwork and without setting up any services, DON J stated, Absolutely not. I've learned over the years that there's appropriate ways to do that . When asked how she would use Resident #1's behavior contract to initiated the discharge, DON J stated, I would reach out to the doctor and I'd tell him, 'This is what we have in place. How do we go about discharging the resident appropriately?' We would have obtained an order. We would have called [CO E.] We would have made a care plan meeting and we would have call the family and the Ombudsman. So that way the family can be aware that she [Resident #1] broke [the behavioral contract] and we need options today. We need to figure out what we're going to do today. Record review of a facility policy titled, Discharging a Resident without a Physician's Approval, dated October 2012, revealed the following: A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice. Record review of a facility policy titled, Transfer or Discharge, Facility Initiated, dated October 2022, revealed the following: Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs services provided by this facility; c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. the health of individuals in the facility would otherwise be endangered; e. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility . f. the facility ceases to operate. A resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others . Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals . If a resident exercises his or her right to appeal a transfer or discharge he or she will not be transferred or discharge while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The Administrator, ADON L, and LVN O were notified of an IJ on 9/22/23 at 5:15 p.m. and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 9/24/23 at 2:21 p.m. and included the following: [The facility] will conduct an in-service training to ensure the staff are trained regarding resident discharges by using [online training] Planning Your Resident Discharge. [Facility] staff are requested to complete this training by 9/23/23; Any staff not available today will be required to do their training when they come back and before they take the floor for their shift. ADMIN will ensure this is done. The facility ensure that staff receive the in-service training by requiring the staff to submit their Certificate of Completion immediately to the ADMIN. Moving forward, future residents who receive a Discharge Notice will have the discharge process and appeals process reviewed and signed by the Admin to ensure the resident's discharge is safe and the appeal process is honored. The mechanism to ensure that all appropriate facility staff are aware of a resident's discharge status begins in the morning meetings. Every morning meeting any potential ADTs are discussed and evaluated for safety and proper process. Moving forward, Admin will ensure all elements of safe discharge as delineated in the training are met. The below list includes all nurses and nurse management staff employed by [the facility] as well as all Directors and PRN staff employed by [the facility]. All agency nurses moving forward and starting immediately today 9/24/23 will be required to complete the training before picking up a shift. The surveyor verification of the Plan of Removal on 9/24/23 was as follows: On 9/24/23 interviews were conducted with 18 staff members (including LVNs and RNs from all 3 shifts, Agency Nurses, and administrative staff) were interviewed. All staff members confirmed they received the education on resident discharges and were able to verbalize examples of how to ensure a safe discharge (i.e. education, return demonstration, and post-discharge follow-up calls.) During an interview on 9/24/23 at 4:25 p.m., the Administrator confirmed she received the training on discharge. Administrator confirmed that potential discharges will be discussed and if the discharge plan does not have all the elements noted in the discharge training, then the resident will not be discharged . Record review of the facility's education document titled, Planning Your Resident discharge, revealed this education included why discharge planning is important, how to prepare a resident for discharge, the importance of involving the resident and family in the discharge planning, and who was involved in the discharge planning. Record review of educational certificates of completion revealed a total of 20 employees and 4 agency nurses have completed the discharge training. On 9/24/23 at 7:06 p.m., RN N, the Administrator, and the interim DON were notified the IJ was removed. However, the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 5 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 had a safe and orderly discharge to a home environment on 9/19/23. During or after the discharge, Resident #1 broke her leg and was hospitalized . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/22/23 at 5:01 p.m. While the IJ was removed on 9/24/23 at 7:06 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were discharged safely. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan. The findings were: Record review of Resident #1's demographics page, dated 9/20/23, revealed CO F was Resident #1's POA and Emergency Contact #2 and CO E was Resident #1's Emergency Contact #1. Record review of Resident #1's diagnoses page, dated 9/20/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with hyperglycemia [high sugar levels in the blood], hypothyroidism [when the thyroid does not produce enough hormones], essential (primary) hypertension, and unspecified vision loss. Record review of Resident #1's quarterly MDS, dated [DATE], revealed the following Item: - G0110. Activities of Daily Living (ADL) Assistance A. Bed Mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The answer for this item was, Two+ persons physical assist. - G0110. Activities of Daily Living (ADL) Assistance B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . The answer for this item was, One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance C. Walk in room - how resident walks between locations in his/her room. The answer for this item was, One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance G. Dressing - how resident puts on/fastens and takes off all items of clothing, including donning [putting on]/removing a prosthesis or TED hose [specialized stockings that prevent blood clots and swelling in the legs.] Dressing includes putting on and changing pajamas and housedresses. The answer for this item was One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance H. Eating - how resident eats and drinks, regardless of skill . Includes intake of nourishment by other means (e.g. tube feeding, total parenteral nutrition [when nutrients are given through the veins], IV fluids administered for nutrition or hydration.) The answer for this item was, One person physical assist. - G0110. Activities of Daily Living (ADL) Assistance I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes . The answer for this item was, Two+ persons physical assist. - G0110. Activities of Daily Living (ADL) Assistance J. Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands . The answer for this item was, One person physical assist. - Q0400: Discharge Plan A. Is active discharge planning already occurring for the resident to return to the community? The answer for this item was No. Record review of Resident #1's BIMS assessment, dated 8/17/23, revealed Resident #1 had a BIMS score of 15, signifying no cognitive impairment. Record review of a document titled, NOTICE OF PROPOSED TRANSFER/DISCHARGE, dated 8/16/23, revealed Resident #1 was given a 30-day discharge notice on 8/16/23 with a discharge date of 9/16/23. The reasons for discharge were list as: Resident refuses MD in facility . Refuses services to include mistreatment of staff to include profanity and belittling staff . Resident has failed . to pay or refused to pay for stay at the Facility AND the resident has not submitted the necessary paperwork for third party payment . If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal . The facility will not discharge/transfer you while the appeal of your discharge/transfer is pending if you exercise your right to appeal unless the failure to discharge/transfer you would endanger your health and safety or that of other residents/other individuals in the Facility. On the signature line was no signature from Resident #1, CO E, or CO F on this discharge notice. Instead, there were the words, Copy handed to [CO E], written by DON J. Record review of a facility document titled, Appendix B. Patient/Family Behavior Contract, dated 8/16/23, revealed the following: Behavior Expectations: 1. Will not belittle staff while discharge is pending [DATE]. 2. Will not use profanity while discharge is pending [DATE]. Will allow [the facility's physician group] to provide care while discharge is pending [DATE]. There was a section below this that read: I have read and understood the above-listed behavioral expectations. I also understand that failure to meet these expectations may result in immediate termination of the relationship between me and the provider/organization. This section had a portion for the resident or responsible party to initial and there was no initial present. At the bottom of this same document there was no signature from Resident #1, CO E, or CO F. There was a signature from the Administrator and DON J as well as the words Family refuses to sign 8/16/23. Next to these words were the Administrator's initials. Record review of a document titled, Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Nursing Facility Discharge, dated 9/15/23, revealed CO F signed for an appeal of Resident #1's discharge on [DATE], before the projected discharge date on Resident #1's 30 day discharge. Record review of a group text message between the Administrator, DON I, and the Director of Activities and Life Enrichment, dated 9/18/23 at 8:53 p.m., revealed the following message from the Administrator to this group: I spoke with [ADON L.] Apparently last week [Resident #1] was so rude to [a CNA] that nurses had to intervene and nurses had to provide care . [ADON L] wants us to evict [Resident #1] based on violating the behavior policy . 1. If we go to appeals court, we have no way to win. They do not evict for behavior. 2. We evict for violation of behavior contract we may get a tag for dumping. DON I responded to the Administrator's message with the following: I agree that abuse at work is hard and if there is any path to cultivating a safe and peaceful work environment, we should take it. I vote for an eviction and amendment to prevent future abuse from residents. Record review of a text message between the Administrator and the Ombudsman, dated 9/19/23 at 2:41 p.m., revealed the following message from the Administrator to the ombudsman: I'm sorry we evicted [Resident #1] based on the abusive behavior to the staff and took her to [CO E's] house. Record review of Resident #1's nursing progress notes from 8/15/23 to 9/19/23 revealed the following: - Nursing progress note, dated 9/19/23 at 2:20 p.m. and written by ADON L: Pt was discharged to her home with [CO E]. Pt was discharged with all medications and instructions/directions for administration. Glucometer [a machine to check blood sugars], strips, and syringes also provided. Pt provided with wheelchair and her personal walker for short distances as sheis [sic] ambulatory. There were no progress notes indicating Resident #1 had an injury. There were no progress notes that indicated coordination of post-discharge care was done with Resident #1, CO E, or CO F prior to Resident #1's discharge on [DATE]. There was no documentation indicating successful coordination other service providers such as home health or provider services. Record review of Resident #1's physician orders, obtained on 9/20/23, revealed Resident #1 had the following orders started on the following dates: - Aspirin EC Low Dose Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day every Mon for blood thinner. Started on 9/11/23. - Furosemide Oral Tablet 20 MG (Furosemide) [a medication used to reduce extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease ] Give 1 tablet by mouth one time a day. Started on 9/6/23. - Levothyroxine Sodium [a thyroid hormone] Tablet 75 MCG Give 1 tablet by mouth in the morning. Started on 7/24/23. - [Brand Name] Check [blood sugar check] at HS at bedtime. Started on 1/8/23. - Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) [a type of injectable, long-acting medication that helps control high blood sugar levels throughout the day] Inject 10 unit subcutaneously in the afternoon. Started on 3/10/23. - Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously in the morning. Started on 6/13/23. - HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) [a type of injectable, fast-acting medication that helps control high blood sugar levels] Inject as per sliding scale: if 131 - 180 = 2 units; 181 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units CALL MD IF >450. Started on 6/1/23. Record review of all of the facility's electronic incident reports revealed no incident of injury involving Resident #1. Record review of the Administrator's statement titled, Ms. [Resident #1], not dated, revealed the following: On the day of eviction, we waited until [Resident #1] had been toileted . We made sure she was clean and dressed and told her maintenance needed in the room, making sure there was no conflict getting her out of her room. We had someone by the door and the bus outside the lift down to make sure it was a quick exit out of the building to reduce conflict. I had staff keep a sheet ready in case she became physically violent, do not grab her wrists or arms because that is how someone gets hurt. Just use the sheet to swaddle her like a baby. We exited the building and went straight to the bus as quickly as possible with no incident. The bus right was 9 min. long . I prepared staff not to respond to [Resident #1] when she was yelling at them and to let only one person, [ADON L], speak because [ADON L] needed to keep the resident calm and did not need too many people at once getting involved. The ADON and Maintenance sat in the back with [Resident #1' to make sure everything stayed calm and safe We had our admissions person call [CO E] first to make sure [CO E] was home and sent her [the admission staff] to the house ahead of us to be certain . Other than [Resident #1] yelling on the 9 min drive, the trip was without incident. We arrived at the home, got [Resident #1] off the bus with no incident and took her to the door. [CO E] refused to unlock the screen door to let us take [Resident #1] inside and said she was calling 911. [Resident #1] put herself out of the wheelchair . Then I instructed all my staff to leave . Leaving [Resident #1] on the porch was without incident other than [CO E] yelling at us. During an interview on 9/20/23 at 11:50 a.m., CO F stated on 9/19/23 at around 2:45 p.m., he received a call from CO E, who stated Resident #1 was just dropped off at her [CO E's] house. CO F stated I guess Resident #1 fell off those steps, so not only did this facility not let [CO E] know they were going to drop [Resident #1] off . When [CO E] opened the door, she saw [the Admissions Staff], [the Administrator], and [Resident #1], and 3 employees. And [CO E] got upset and [CO E] was going to call the police. And then that's when [Resident #1] fell off the [concrete porch] stairs and she hurt her back. I don't know if they [the staff and CO E] weren't paying attention or if [Resident #1] lost her balance. [CO E] stated she had EMS out there and I think the fire department . So [Resident #1's] injuries could have been avoided if [the staff] didn't drop her off. CO F stated neither he nor CO E were informed that Resident #1 was going to be discharged on 9/19/23. CO F stated Resident #1 was placed in the facility because Resident #1 lost her eyesight and had diabetes. CO F stated Resident #1 needed assistance with orientation for eating and required assistance with walking. CO F stated Resident #1 cannot cook. CO F stated no assistance can be provided to Resident #1 at CO E's house because CO E cannot provide assistance to Resident #1. CO F stated, that's why [Resident #1 is] in [the facility.] During an interview on 9/20/23 at 3:39 p.m., Agency LVN K stated she worked with Resident #1 and worked on 9/19/23. Agency LVN K stated she did not know anything about Resident #1's discharge on [DATE] because Resident #1's discharge occurred before her shift from 2:00 pm to 10:00 p.m. Agency LVN K stated Resident #1 was blind and needed assistance with transfers and needed assistance with walking to and from the bathroom to her [Resident #1's] bed. During an interview on 9/20/23 at 4:52 p.m., when asked how did the discharge planning process start and how did the discharge planning progress, ADON L stated, I don't have too much input. I haven't been phased that much in decision-making or keeping up with the status as of yet. The ADON stated the Administrator and other staff members, like the Admissions Staff, were also involved in the discharge, but the Administrator spearheads the admissions and discharges. When asked how the facility involved a resident in the discharge, ADON L stated, families will be contacted and asked to come in and have a meeting and at the meeting is where the discussion will happen, how to better meet [the resident's] needs . It's important to have the family or the loved one involved. So we try to get as much input as possible. When asked what the facility's policies stated about facility-initiated discharges, ADON L stated, I'm not able to tell you off the top off my head. ADON L stated Resident #1 was diabetic, blind, petite, and wanted things done in a particular fashion. ADON L stated, When asked if Resident #1 required 24-hour care, ADON L stated, my personal opinion, I believe [Resident #1] can live at home. I know she can't self-administer insulin due to her eyesight, but I don't think she needs 24-hour care. During an observation and interview on 9/21/23 at 8:10 a.m., Resident #1 was observed lying in bed in a local hospital. Resident #1 stated she had difficulty walking and she needed someone with her to help her bathe and help her administer insulin. Resident #1 stated, I can't do my insulin. I'm too afraid to put it into the vein. Resident #1 stated she did not have assistance in CO E's house. Resident #1 stated CO E stated CO E also had poor vision and could not administer her [Resident #1's] insulin. Resident #1 stated she and CO E cannot cook. Resident #1 stated she did not have a home health agency or a provider. Resident #1 stated, I didn't know I was going to be discharged . I'm still shaking from it. It was awful. Resident #1 stated on 9/19/23 at around 2:00 p.m., CNA A told her someone was coming to work in her room so they had to get her out. Resident #1 stated, and before I knew it [CNA A] was taking me out of the room in a rush. I thought it was weird they were going to do the bathroom and the light. They put me in a wheelchair and rushed me out . I got to [CO E's] house . they pushed me up on the wheelchair on that porch . Somewhere my foot got stuck [during the transport.] My foot was fractured . [CO E] called 911 because I felt I was in pain. During an interview on 9/21/23 at 9:45 a.m., Representative M stated medical records of the local hospital were outsourced and any records this surveyor requested will be sent within 3-5 business days. No records were released to this surveyor at the time of this interview. During an interview on 9/21/23 at 9:53 a.m., Representative G stated Resident #1 was admitted to the hospital due to a fall at [CO E's] house after Resident #1's dismissal from the nursing home. Representative G stated Resident #1 had a fracture to her left distal fibular [her left ankle] and had to wear a boot at this time. During an interview on 9/21/23 at 10:47 a.m., LVN B stated Resident #1 was blind, was not able to get up by herself, required stand-by assistance when walking, required set-up assistance to eat, and required stand-by supervision during baths. LVN B stated she did not think Resident #1 would be able to administer insulin herself. LVN B stated Resident #1 tended to take a lot of time to do activities of daily living such as bathing and washing her hands. LVN B stated it would typically take 20-25 minutes. LVN B stated, it takes up too much time as far as doing that.They said she's refused stuff as far as not letting her blood sugar checked. LVN B stated she worked on 9/19/23 and towards the end of her shift (at around 2:00 p.m.) ADON L told her [LVN B] that she [ADON L] needed Resident #1's medication. LVN B stated from ADON L was in charge of Resident #1's discharge. During an interview on 9/21/23 at 11:13 a.m. HA C stated she took care of Resident #1. HA C stated, Usually I helped [Resident #1] because she was blind. I helped her to the restroom. I assisted her. I helped her put her shoes on. I helped dress her. HA C stated she worked on 9/19/23, but did not know anything about Resident #1's discharge that day. In a follow-up interview on 9/21/23 at 12:09 p.m., when asked if Resident #1 met criteria for long-term care, ADON L stated, Yes, [Resident #1] could not administer her own insulin. ADON L stated, a lot of assistance was mostly like a stand-by assist. Because [Resident #1] is ambulatory, she does her own personal hygiene like brushing her teeth and oral care . Most of it was stand-by and set-up for her meals. She didn't need assistance with eating, but you had to tell her where it [the food] was. ADON L stated Resident #1 would refuse blood sugar checks and insulin, would make accusations, and was verbally abusive. ADON L stated Resident was discharged because of her behaviors. ADON L stated the administrator initiated Resident #1's discharge on Monday, 9/18/23. ADON L stated, I think there were some complaints that may have happened on the weekend or Monday. ADON L stated she believed DON J and the Ombudsman attempted to find alternative placements, but the family ultimately refused to transfer. ADON L stated Resident #1 wanted to stay in the facility. ADON L stated on Tuesday, 9/19/23, the Administrator told her [ADON L] Resident #1 was being discharged . ADON L stated at around 2:00 p.m. she then went to gather Resident #1's medications and prepare documentation for the discharge. ADON L stated, I said [to Resident #1], we're going to go over your medication with you because you're discharged . And [Resident #1] said 'hmph, I'd like to see that.' ADON L stated while she was attempting to explain the paperwork, [Resident #1] was yelling, I don't care, I don't care! ADON L stated she did not know if any services were coordinated with Resident #1 or CO E. ADON L stated shortly after 2:00 p.m., Resident #1 was placed in a wheelchair, taken to the van and then driven to CO E's house. ADON L stated she, the Administrator, the Director of Activities and Life Enrichment, the Admissions Staff, and the Maintenance Technician went with Resident #1 during the journey. ADON L stated upon arrival, CO E closed the door and would not allow the staff to enter the home. ADON L stated, [CO E] says 'I'm going to close the door and I'm going to call the cops.' ADON L stated Resident #1 transferred herself to the steps of the concrete porch and sat there. ADON L stated she did not see Resident #1 fall from the porch. ADON L stated CO E did not open the door and she, along with the rest of the facility staff, left. Continuing ADON L's follow-up interview on 9/21/23 at 12:09 p.m., when asked how she ensured Resident #1's discharge was safe, ADON L stated, I went over [Resident #1's] meds with her. I didn't get a chance to go inside [CO E's home] to see what [Resident #1] needed. When asked what sort of things should be done before a resident was discharged , ADON L stated, I'd like to be able to do an on-site visit if [Resident #1] needs a refrigerator for her medication or special equipment or if there's a trip hazard or just safety for the resident. I'd like to be part of that. This was a very different discharge. My involvement was very limited. When asked how CO E's home was going to meet Resident #1's needs, ADON L stated, I'm not aware of who else was in the home. I know there were others living in the home because there were vehicles parked on the lawn. But I wouldn't have-I would hate to answer or assume-I don't want to make any assumptions because my involvement with the decisions of the date and time and the process, it was very limited. I wasn't involved with preparing the discharge for [Resident #1]. When asked if there was anything she would have changed about Resident #1's discharge, ADON L stated, I would have appreciated a more 24-hour notice so I could make sure that I could speak with the family member and I could coordinate with the doctor in case [Resident #1] needed something further outside of [the facility.] When asked if she would have sent Resident #1 to another place, ADON L stated, Me, personally, I think home with home health is probably best for her or activities with an adult day care would probably be best for her. When asked if she felt Resident #1's discharge location was safe, ADON L stated, [CO E's house] didn't look dilapidated. It looked like a nice home. The environment in the home didn't give me that it wasn't appropriate for [Resident #1]. The yard was neatly kept and the house looked clear. ADON L stated since Resident #1 was discharged , she had not received any new education regarding discharge. During an interview on 9/21/23 at 2:06 p.m., CNA A stated he told Resident #1 her room needed maintenance in order to get Resident #1 out of the room. CNA A stated, Because she would have taken a long time to get ready. During an interview on 9/21/23 at 3:19 p.m., Physician D stated Resident #1 was his patient. Physician D stated he did not know anything about Resident #1's discharge and only heard about it on the day of this interview, 9/21/23. Physician D stated he was not aware of any home health services or provider services for Resident #1. When asked if he felt a home was a safe discharge location for Resident #1, Physician D stated, Her home, yeah. [Resident #1] came from home and, you know, she was refusing care. During a joint interview with the Maintenance Supervisor and the Maintenance Technician on 9/21/23 at 3:44 p.m., the Maintenance Supervisor stated he and the Maintenance Technician assisted in transporting Resident #1 to CO E's house on 9/19/23. The Maintenance Supervisor stated he was informed by the Administrator to assist in discharging Resident #1 around 11:30 a.m. to 12:00 p.m. The Maintenance Technician stated, At first, [Resident #1] didn't know what was going on. And then [ADON L] told her and [Resident #1] said, 'oh, you are?' And then [Resident #1] realized what was going on and at first [Resident #1] didn't believe it. [Resident #1] said, 'you're not taking me to [CO E.]' The Maintenance Technician stated Resident #1 was yelling and screaming on the bus when Resident #1 did not know what was happening. Both the Maintenance Supervisor and the Maintenance Technician denied Resident #1 fell on the porch during the discharge. During an interview on 9/21/23 at 4:40 p.m., CO E stated on 9/19/23 she received a call from the Admissions Staff and the Admissions Staff stated she wanted to give CO E a social security form for Resident #1. CO E stated when she [CO E] came to the door she saw the Admissions Staff member standing on her porch with Resident #1's medications and then the facility's van arrived to her house with Resident #1. CO E stated, I wasn't warned. I wasn't even told they were going to bring her. What I was waiting for was for [the Admissions Staff] to drop off the social security paper and there weren't even papers. It was the records from [the facility.] CO E stated when she saw the Administrator arrive she shut the door and called the police. CO E stated, [Resident #1] said they [the staff] were in a hurry and they messed up her ankle. And [Resident #1] has a boot because the [hospital] doctor said [Resident #1] didn't require surgery. So [Resident #1] has to wear the boot. [Resident #1' said, [CO E] they were in a hurry and they didn't even care how they were handling me. And I don't know if she fell also. I don't know. I didn't see her [fall]. I just saw her when they were getting her to the porch. CO E stated Resident #1 was placed in the facility because no one in Resident #1's family could take care of Resident #1. CO E stated, [Resident #1's] diabetes is not easy. [Resident #1] needs her insulin . sometimes her sugars are very high and sometimes when [Resident #1] wakes up her sugars are very low . And she's completely blind. She can't see at all, so she cannot cook, can't drive, can't even go to the doctor's appointment. She needs help bathing also, and getting her to the restroom. She needs a lot of care. CO E stated Resident #1 could not administer her own insulin. CO E stated no assistance can be provided to Resident #1 at CO E's home. During an interview on 9/22/23 at 8:47 a.m., the Administrator stated, Typically I wouldn't play a role in discharge, other than I sign off [on a form] saying I know they [the resident] went out. When asked how she provided oversight to the discharge process, the Administrator stated, I rely on the Director of Nursing and they tell me what they're doing or why. And we go over the ADTs at the morning meeting and then I sign off on the paperwork saying yes, that's what happened. And that I know where they're going. When asked how the discharge planning started and how did the discharge planning process, the Administrator stated, In general, the discharge would depend on where [the resident is] being discharged to, whether it's a hospital or a skilled facility or a home . I'm not really part of that. The Administrator stated if a resident was going to be discharged home, they would work with the family and speak with the family about the ramifications of not being in a nursing home. The Administrator stated, the general idea is notify the family and the resident and prepare for safe discharge. They [the family and the resident] have the right to appeal, unless there's documented evidence that the resident's return would endanger the health and safety of the other residents. The Administrator stated a resident was able to be discharged anytime the family wants them [the resident] to leave. Anytime they [the resident] needs skilled care because we can't provide care for them or meet their needs. The Administrator stated, I've never done an eviction, so I've never done an appeals hearing. When asked how she ensured a resident's discharge was safe, the Administrator stated, we go over it [the discharge] in the morning meeting. The [DON] tells me what's happening and I sign off on the paperwork. Continuing the Administrator's interview on 9/22/23 at 8:47 a.m., the Administrator stated they determined the facility could care for Resident #1 based on Resident #1's medical necessity, financial eligibility, and because there were no records of any behavior such as physical violence, smoking status, or elopement risk . Medically, yes, [Resident #1] met the standard for nursing home care based on her records. When asked what services the facility was providing Resident #1, the Administrator stated, There are two things: visual impairment and diabetes-insulin . And basically [Resident #1] gets one pill a day and it's really the diabetes that she can't manage it . If she had family support, then that wouldn't have been a problem. It's just checking your blood sugar and giving an injection but [Resident #1] had no family that would help her. No family would take her in. Prior to that [Resident #1's admission] she lived with [a family member], but then [the family member] dropped her off and took off . [CO F] works all the time and he doesn't want to be involved in this . [CO E] says, 'I'm too old to take care of her.] And none of them wanted her to live with them and allow community services to come in and help [Resident #1] with her medications. The Administrator stated there were attempts to transfer Resident #1 to other facilities, but ultimately the family refused the transfer. The Administrator stated Resident #1 was discharged because Resident #1 was abusive to the staff . it had reached a place where staff were quitting, crying. When asked who initiated Resident #1's discharge, the Administrator stated, As a group we talked about what to do and [DON I] had to say well, that's what we wanted to do. The Administrator stated on 9/18/23, she was informed by the Ombudsman that Resident #1 appealed her discharge. The Administrator stated the decision to discharge Resident #1 was made on the evening of 9/18/23. Continuing the Administrator's interview on 9/22/23 at 8:47 a.m., the Administrator stated on 9/19/23, she instructed the Admissions Staff to arrive at CO E's house to verify CO E was home, take photographs of the home so the other facility staff can identify CO E's home, and attempt to gain entry into the house in order to assist the other staff members in entering the home when the other staff members arrived. The Administrator stated, meanwhile, ADON L got Resident #1's medications ready and obtain an extra glucometer for Resident #1. The Administrator stated she instructed CNA A told Resident #1 her room required maintenance in order to get Resident #1 out of the room. The Administrator stated she instructed the Director of Activities and Life Enrichment to bring the facility's van around and Resident #1 was loaded into the van in a wheelchair. The Administrator stated one of the staff members had a blanket to swaddle Resident #1 if Resident #1 became physically violent. The Administrator stated she instructed the Maintenance Director to also follow behind the facility van and also had the Maintenance Technician inside the facility van with Resident #1 so both the Maintenance Director and the Maintenance Technician can assist with transporting Resident #1 into CO E's home. The Administrator stated ADON L was also on the journey to CO E's house in order to talk to Resident #1 and keep Resident #1 calm. The Administrator stated, [ADON L] told [Resident #1], 'we're going to be at [CO E's] house in a few minutes. And [Resident #1] said, '[TRUNCATED]