Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure the facility's arbitration agreement addressed residents' right to rescind the agreement within 30 calendar days of signing the agreement. The findings include: The facility's AGREEMENT TO ARBITRATE document did not address residents' right to rescind the agreement within 30 calendar days of signing the agreement. Review of the facility's AGREEMENT TO ARBITRATE document failed to reveal explicit language addressing residents' and/or residents' representatives' right to rescind the agreement within 30 calendar days of signing it. (A signed AGREEMENT TO ARBITRATE document for one (1) of the sampled residents was provided to the survey team.) On 3/13/24 at 9:24 a.m., the facility's Admissions Director reported they did not see language, in the document, addressing the right to rescind within 30 days of signing the facility's AGREEMENT TO ARBITRATE document. The Admissions Director reported the right to rescind within 30 days of signing the AGREEMENT TO ARBITRATE document is discussed when it is signed but isn't documented. The facility's Arbitration Policy (with an effective date of 10/24/22) included the following statement: Admissions personnel must explain to the Resident [sic] or their personal representative that if they sign the agreement, they have the explicit right to rescind the agreement within 30 calendar days of signing it. On 3/13/24 at 4:03 p.m., the survey team met with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Consultant, and Regional MDS (Minimum Data Set) Nurse. During this meeting, the failure of the facility's AGREEMENT TO ARBITRATE document to explicitly include information about the right to rescind the agreement within 30 calendar days of signing it was discussed.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure the facility's arbitration agreement addressed the selection of a venue that would be convenient to both parties. The findings include: The facility's AGREEMENT TO ARBITRATE document did not address the selection of a venue. (A signed AGREEMENT TO ARBITRATE document for one (1) of the sampled residents was provided to the survey team.) On 3/13/24 at 10:38 a.m., the surveyor discussed the facility's AGREEMENT TO ARBITRATE document with the facility's Administrator and Admissions Director. The Admissions Director confirmed the agreement did not address selecting the location. The Administrator and Admissions Director reported the plan would be for a mutually agreed upon location to be selected. The facility's Arbitration Policy (with an effective date of 10/24/22) did not address the selection of a location. On 3/13/24 at 4:03 p.m., the survey team met with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Consultant, and Regional MDS (Minimum Data Set) Nurse. During this meeting, the failure of the facility's AGREEMENT TO ARBITRATE document to address the selection of a location was discussed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to provide the receiving provider with the appropriate information to include basis for the transfer, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advanced Directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information including a copy of the resident's discharge summary and failed to document information provided to the receiving provider for 10 of 29 residents (Resident #267, Resident #104, Resident #83, Resident #90, Resident #36, Resident #115, Resident #218, Resident #19, Resident #25, and Resident #69). The findings included: 1. The facility staff failed to provide the receiving provider with information for on-going care when Resident #104 was transferred to the hospital. The clinical record of Resident #104 was reviewed 1/23/19 through 1/28/19. Resident #104 was admitted to the facility 12/10/18 and readmitted [DATE] with diagnoses that included but not limited to hypokalemia, dementia with behavioral disturbances, atrial fibrillation, restlessness and agitation, insomnia, infected left femur fracture, metabolic encephalopathy, urinary tract infection, and hypertension. Resident #104's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/9/19 assessed the resident with a brief interview for mental status (BIMS) as 4/15. The departmental note dated 12/19/18 at 2:18 p.m. read in part She is leaving facility at this time for direct admit to RGH (name of hospital omitted). Transported via (name of ambulance service omitted) and two attendants. The departmental notes were reviewed on 1/24/19. The 12/19/18 5:32 p.m. departmental note read, RGH (name of hospital) nurse called and wanted to know why resident was there. She did not get a report from this facility as to why. They do have a bed and she is been admitted (sic) at this time. The clinical record had no documentation of contact information, what information was provided to the hospital, advanced directive information, resident representative contact information, contact information from the facility, transfer form, comprehensive careplan goals sent, or any special instructions or bed hold offer. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the facility was just beginning to work on a form called Interact but had to be completed. The surveyor requested the facility policy on transfers/discharges. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The director of nursing did not provide a policy for transfers/discharges prior to the exit conference on 1/28/19. 2. The facility staff failed to provide Resident #90's transfer/discharge information to the receiving provider when transferred to the hospital on [DATE] and 11/4/18. The clinical record of Resident #90 was reviewed 1/23/19 through 1/28/19. Resident #61 was admitted to the facility 3/13/17 and readmitted [DATE] and 11/7/18 with diagnoses that included but not limited to vascular dementia without behavioral disturbances, type 2 diabetes mellitus, hypothyroidism, cervical disc disorder, right femur intertrochanteric fracture, osteoporosis, gastro-esophageal reflux disease, contusion of scalp, chronic diastolic heart failure, cerebral infarction, dysphagia, major depressive disorder, polyneuropathy, anemia, hypertension, and hyperlipidemia. Resident #90's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/2/19 assessed the resident with a brief interview for mental status (BIMS) as 7/15. A telephone order dated 10/29/18 read May send resident to ER (emergency room) for eval (evaluation) & treat (treatment). The surveyor reviewed the departmental note dated 10/29/18 10:44 p.m. The note read in part: Late Entry: This nurse was called to therapy gym. Resident was found in floor on right side. Resident stated she had lost her balance and fell to the floor. Upon assessment resident stated she had pain in her right hip and right side of her head on a pain scale of 4 out of 10. Right side of head had hematoma present. Resident was assisted to wheelchair and to her room. MD (medical doctor) notified (name omitted) concerned of resident on Coumadin with the fall and wanted resident to be sent to ER (name omitted). Transport arrived at 1820 (6:20 p.m.) and resident left via stretcher. Departmental note dated 10/30/18 10:44 a.m. read in part Resident admitted to hospital. A second physician order dated 11/4/18 read May send out to ER (name omitted) for eval & tx (treatment) due to increased confusion, combativeness, trying to harm self and decreased O2 (oxygen) sat (saturation). The surveyor reviewed the departmental note dated 11/4/18 6:46 p.m. The note read Late entry 6p.m. Resident noted to have increased confusion with big change in personality. She has been very combative to staff this shift. Resident can normally hold a normal conversation, but cannot at this time. She began doing things to herself, such as, pulling her own hair, bending fingers backwards while looking at staff and stating look here, I'm going to tell them you did this. You are going to be accused of it. This is not normal behavior for this resident. This nurse sent to ER for eval and tx. Physician aware and RP (responsible party) agrees with this nurses decision and is meeting resident at hospital. The clinical record did not have documentation of resident information provided to the receiving provider of the advanced directive, contact information of the resident representative or contact information of the sending facility, comprehensive care plan goals, discharge summary/transfer form, or special instructions for care or bed hold offer. The surveyor informed the director of nursing of the above information not found in the clinical record for either of Resident #61's transfers to the emergency room and subsequent admissions to the hospital on [DATE] and 11/4/18 on 1/27/19 at 3:55 p.m. The director of nursing stated the only information sent with the resident was the face sheet and the medication administration record (MAR). The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the facility was just beginning to work on a form called Interact but had to be completed. The surveyor requested the facility policy on transfers/discharges. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The director of nursing did not provide a policy for transfers/discharges prior to the exit conference on 1/28/19. 3. The facility staff failed to provide transfer/discharge information to the receiving provider when Resident #218 was transferred to the hospital. The clinical record of Resident #218 was reviewed 1/23/19 through 1/28/19. Resident #218 was admitted to the facility 4/6/18 and readmitted [DATE] with diagnoses that included but not limited to acute osteomyelitis, sepsis, cellulitis of right lower limb and chronic respiratory failure with hypercapnia. Resident #218's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/14/19 assessed the resident with a brief interview for mental status (BIMS) as 15/15. The clinical record revealed three emergency room visits with two requiring hospitalizations. Resident #218 was sent to the emergency room on [DATE] for abdominal pain and constipation. There was documentation that a report was called to the emergency room but no further evidence of what information was provided to the receiving provider. The clinical record revealed Resident #218 was admitted to the hospital 1/4/19 as evidenced by the physician discharge summary for 1/4/19-1/7/19. The departmental note dated 1/4/19 at 3:43 a.m. read Resident left facility via wheelchair with son at 3:40 a.m. to go to an appointment. No skin issues or distress noted. The departmental note dated 1/4/19 at 11:44 a.m. read Resident continues to be out of facility. The departmental note dated 1/4/19 at 10:44 p.m. read Resident remains OOF (out of facility) at hospital. None of the notes dated 1/4/19 detail information sent to the receiving provider when the resident did not return to the facility on 1/4/19. The clinical record revealed Resident #218 was admitted to the hospital 1/18/19-1/21/19 for acute kidney injury. The departmental note dated 1/18/19 at 1:53 p.m. read in part Resident complains of feeling bad. Could not state exactly what her complaints were more specifically. Did state she was having double vision and that her vision was wavey. MD (medical doctor-name omitted) notified. Telephone order received to send patient to ER (emergency room) for evaluation and treatment of complaints. The departmental note dated 1/18/19 at 2:24 p.m. read EMS (emergency medical services) notified for transport to the ED (emergency department), report called to ED (name omitted). The departmental note dated 1/19/19 at 10:32 a.m. read in part Resident was admitted [DATE] for acute kidney injury. None of the transfers/discharges/hospitalizations had documentation in the clinical record of information provided to the receiving provider-contact information of the practitioner, contact information of the resident representative, transfer form, advanced directive, comprehensive care plan goals, or any pertinent information pertaining to the ongoing care of the resident or offer of bed-hold information. The survey team met with the administrator, the director of nursing (DON), and the corporate registered nurse on 1/24/19 at 4:14 p.m. and informed them of the required information sent to the hospital when a resident was transferred. The DON stated a face sheet and a medication administration record (MAR). The DON stated the facility was just beginning to work on a form called Interact but had to be completed. The surveyor requested the facility policy on transfers/discharges. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The director of nursing did not provide a policy for transfers/discharges prior to the exit conference on 1/28/19. 4. The facility staff failed to provide transfer/discharge information to the receiving provider when Resident #25 was sent to the hospital 1/11/19. The clinical record of Resident #25 was reviewed 1/23/19 through 1/28/19. Resident #25 was admitted to the facility 2/10/18 and readmitted [DATE] with diagnoses that included but not limited to acute and chronic respiratory failure with hypoxia, hypothyroidism, hypercholesterolemia, major depressive disorder, hypertension, acute bronchitis, repeated falls, hyperlipidemia, pressure ulcer stage 2 right buttock, and discitis. Resident #25's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/21/18 assessed the resident with a brief interview for mental status (BIMS) as 15/15. The clinical record revealed a telephone order dated 1/11/19 that read May send out to ER (emergency room) (name of hospital omitted) for eval (evaluation)/tx (treatment) d/t (due to) fall & c/o (complaints of) pain. The surveyor reviewed the 1/11/19 6:07 p.m. departmental note. The note read in part: @1728 (5:28 p.m.) staff stated that resident was in the floor. Resident was observed to be laying on his left side on the left side of the bed. Blood was coming from resident's head and left forearm. Pressure was held onto (sic) bleeding areas. 911 was called for transport. Resident stated that his left hip, left shoulder and head was hurting. Unable to do neuro checks due to resident's refusal. MD (medical doctor) and RP (responsible party) aware. Rescue squad arrived x3 attendants. Resident was assisted onto the stretcher x3 attendants and 2 employees. Resident left the facility at this time. Report was called to ER (emergency room) (name omitted). The departmental note failed to have evidence of information sent with Resident #25 when the resident was transferred to the hospital-no transfer form/discharge form, contact information, resident representative contact information, comprehensive care plan goals, advanced directive, or any pertinent tests or bed hold information. The survey team had discussed the concerns with transfer/discharges and information sent with residents in the end of the day meeting on 1/24/19 at 4:14 p.m. with the administrator, the director of nursing (DON) and the corporate registered nurse. The DON stated information sent with the resident when transferred included the face sheet and the medication administration record. No further information was provided prior to the exit conference on 1/28/19. 5. There were six other residents who were transferred to hospitals and the facility staff failed to provide information to the receiving providers. Those residents were identified as Resident #267, Resident #83, Resident #36, Resident #115, Resident #19, and Resident #69. The survey team met with the administrator, the director of nursing (DON) and the corporate registered nurse on 1/24/19 at 4:14 p.m. and during the meeting asked what information was provided to the receiving provider when transferred to the hospital. The DON stated the face sheet and the medication administration record were sent. The DON stated the facility was just beginning to work on paperwork to be sent with residents when they are transferred to the hospital. The DON stated the facility was reviewing a form called Interact for transfers. No further information was provided prior to the exit conference on 1/28/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to provide written notice of transfer/discharge to include the effective date of transfer or discharge; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman and documentation in the medical record that the notice was sent to the Ombudsman for 10 of 29 residents (Resident #287, Resident #104, Resident #83, Resident #90, Resident #36, Resident #115, Resident #218, Resident #19, Resident #25, and Resident #69). The findings included: 1. The facility staff failed to provide written notice of transfer to the resident and the resident representative when Resident #104 was transferred to the hospital and failed to document in the medical record ombudsman notification. The clinical record of Resident #104 was reviewed 1/23/19 through 1/28/19. Resident #104 was admitted to the facility 12/10/18 and readmitted [DATE] with diagnoses that included but not limited to hypokalemia, dementia with behavioral disturbances, atrial fibrillation, restlessness and agitation, insomnia, infected left femur fracture, metabolic encephalopathy, urinary tract infection, and hypertension. Resident #104's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/9/19 assessed the resident with a brief interview for mental status (BIMS) as 4/15. The departmental note dated 12/19/18 at 2:18 p.m. read in part She is leaving facility at this time for direct admit to RGH (name of hospital omitted). Transported via (name of ambulance service omitted) and two attendants. The departmental notes were reviewed on 1/24/19. The 12/19/18 5:32 p.m. departmental note read, RGH (name of hospital) nurse called and wanted to know why resident was there. She did not get a report from this facility as to why. They do have a bed and she is been admitted (sic) at this time. The clinical record had no documentation that the written notice of transfer was given to the resident and the resident representative and there was no ombudsman notification documented in the clinical record. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the facility was just beginning to work on a form called Interact but had to be completed. The surveyor requested the facility policy on transfers/discharges. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The director of nursing did not provide a policy for transfers/discharges prior to the exit conference on 1/28/19. 2. The facility staff failed to provide written notice of transfer to the resident and the resident representative when Resident #90 was transferred to the hospital on [DATE] and 11/4/18 and failed to document in the medical record ombudsman notification. The clinical record of Resident #90 was reviewed 1/23/19 through 1/28/19. Resident #90 was admitted to the facility 3/13/17 and readmitted [DATE] and 11/7/18 with diagnoses that included but not limited to vascular dementia without behavioral disturbances, type 2 diabetes mellitus, hypothyroidism, cervical disc disorder, right femur intertrochanteric fracture, osteoporosis, gastro-esophageal reflux disease, contusion of scalp, chronic diastolic heart failure, cerebral infarction, dysphagia, major depressive disorder, polyneuropathy, anemia, hypertension, and hyperlipidemia. Resident #90's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/2/19 assessed the resident with a brief interview for mental status (BIMS) as 7/15. A telephone order dated 10/29/18 read May send resident to ER (emergency room) for eval (evaluation) & treat (treatment). The surveyor reviewed the departmental note dated 10/29/18 10:44 p.m. The note read in part: Late Entry: This nurse was called to therapy gym. Resident was found in floor on right side. Resident stated she had lost her balance and fell to the floor. Upon assessment resident stated she had pain in her right hip and right side of her head on a pain scale of 4 out of 10. Right side of head had hematoma present. Resident was assisted to wheelchair and to her room. MD (medical doctor) notified (name omitted) concerned of resident on Coumadin with the fall and wanted resident to be sent to ER (name omitted). Transport arrived at 1820 (6:20 p.m.) and resident left via stretcher. Departmental note dated 10/30/18 10:44 a.m. read in part Resident admitted to hospital. A second physician order dated 11/4/18 read May send out to ER (name omitted) for eval & tx (treatment) due to increased confusion, combativeness, trying to harm self and decreased O2 (oxygen) sat (saturation). The surveyor reviewed the departmental note dated 11/4/18 6:46 p.m. The note read Late entry 6 p.m. Resident noted to have increased confusion with big change in personality. She has been very combative to staff this shift. Resident can normally hold a normal conversation, but cannot at this time. She began doing things to herself, such as, pulling her own hair, bending fingers backwards while looking at staff and stating look here, I'm going to tell them you did this. You are going to be accused of it. This is not normal behavior for this resident. This nurse sent to ER for eval and tx. Physician aware and RP (responsible party) agrees with this nurses decision and is meeting resident at hospital. The clinical record had no documentation that the written notice of transfer was given to the resident and the resident representative and there was no ombudsman notification documented in the clinical record. The surveyor informed the director of nursing of the above information not found in the clinical record for either of Resident #90's transfers to the emergency room and subsequent admissions to the hospital on [DATE] and 11/4/18 on 1/27/19 at 3:55 p.m. The director of nursing stated the only information sent with the resident was the face sheet and the medication administration record (MAR). The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the facility was just beginning to work on a form called Interact but had to be completed. The surveyor requested the facility policy on transfers/discharges. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The director of nursing did not provide a policy for transfers/discharges prior to the exit conference on 1/28/19. 3. The facility staff failed to provide written notice of transfer to the resident and resident representative and failed to document ombudsman notification in the clinical record when Resident #218 was transferred to the hospital. The clinical record of Resident #218 was reviewed 1/23/19 through 1/28/19. Resident #218 was admitted to the facility 4/6/18 and readmitted [DATE] with diagnoses that included but not limited to acute osteomyelitis, sepsis, cellulitis of right lower limb and chronic respiratory failure with hypercapnia. Resident #218's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/14/19 assessed the resident with a brief interview for mental status (BIMS) as 15/15. The clinical record revealed three emergency room visits with two requiring hospitalizations. Resident #218 was sent to the emergency room on [DATE] for abdominal pain and constipation. There was documentation that a report was called to the emergency room but no further evidence of what information was provided to the receiving provider. The clinical record had no documentation that the written notice of transfer was given to the resident and the resident representative on 11/24/18 and there was no ombudsman notification documented in the clinical record. The clinical record revealed Resident #218 was admitted to the hospital 1/4/19 as evidenced by the physician discharge summary for 1/4/19-1/7/19. The departmental note dated 1/4/19 at 3:43 a.m. read Resident left facility via wheelchair with son at 3:40 a.m. to go to an appointment. No skin issues or distress noted. The departmental note dated 1/4/19 at 11:44 a.m. read Resident continues to be out of facility. The departmental note dated 1/4/19 at 10:44 p.m. read Resident remains OOF (out of facility) at hospital. The clinical record had no documentation that the written notice of transfer was given to the resident and the resident representative on 1/4/19 and there was no ombudsman notification documented in the clinical record. The clinical record revealed Resident #218 was admitted to the hospital 1/18/19-1/21/19 for acute kidney injury. The departmental note dated 1/18/19 at 1:53 p.m. read in part Resident complains of feeling bad. Could not state exactly what her complaints were more specifically. Did state she was having double vision and that her vision was wavey. MD (medical doctor-name omitted) notified. Telephone order received to send patient to ER (emergency room) for evaluation and treatment of complaints. The departmental note dated 1/18/19 at 2:24 p.m. read EMS (emergency medical services) notified for transport to the ED (emergency department), report called to ED (name omitted). The departmental note dated 1/19/19 at 10:32 a.m. read in part Resident was admitted [DATE] for acute kidney injury. The clinical record had no documentation that the written notice of transfer was given to the resident and the resident representative and there was no ombudsman notification documented in the clinical record. The survey team met with the administrator, the director of nursing (DON), and the corporate registered nurse on 1/24/19 at 4:14 p.m. and informed them of the required information sent to the hospital when a resident was transferred. The DON stated only a face sheet and a medication administration record (MAR) are sent. The DON stated the facility was just beginning to work on a form called Interact but had to be completed. The surveyor requested the facility policy on transfers/discharges. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The director of nursing did not provide a policy for transfers/discharges prior to the exit conference on 1/28/19. 4. The facility staff failed to provide written transfer/discharge information to the resident and resident representative and failed to document ombudsman notification in the clinical record when Resident #25 was sent to the hospital 1/11/19. The clinical record of Resident #25 was reviewed 1/23/19 through 1/28/19. Resident #25 was admitted to the facility 2/10/18 and readmitted [DATE] with diagnoses that included but not limited to acute and chronic respiratory failure with hypoxia, hypothyroidism, hypercholesterolemia, major depressive disorder, hypertension, acute bronchitis, repeated falls, hyperlipidemia, pressure ulcer stage 2 right buttock, and discitis. Resident #25's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/21/18 assessed the resident with a brief interview for mental status (BIMS) as 15/15. The clinical record revealed a telephone order dated 1/11/19 that read May send out to ER (emergency room) (name of hospital omitted) for eval (evaluation)/tx (treatment) d/t (due to) fall & c/o (complaints of) pain. The surveyor reviewed the 1/11/19 6:07 p.m. departmental note. The note read in part: @1728 (5:28 p.m.) staff stated that resident was in the floor. Resident was observed to be laying on his left side on the left side of the bed. Blood was coming from resident's head and left forearm. Pressure was held onto (sic) bleeding areas. 911 was called for transport. Resident stated that his left hip, left shoulder and head was hurting. Unable to do neuro checks due to resident's refusal. MD (medical doctor) and RP (responsible party) aware. Rescue squad arrived x3 attendants. Resident was assisted onto the stretcher x3 attendants and 2 employees. Resident left the facility at this time. Report was called to ER (emergency room) (name omitted). The departmental note failed to have evidence that written notice of transfer/discharge information was provided to the resident and resident representative when Resident #25 was transferred to the hospital and there was no documentation of ombudsman notification found in the clinical record. The survey team had discussed the concerns with transfer/discharges and information sent with residents in the end of the day meeting on 1/24/19 at 4:14 p.m. with the administrator, the director of nursing (DON) and the corporate registered nurse. The DON stated information sent with the resident when transferred included the face sheet and the medication administration record. No further information was provided prior to the exit conference on 1/28/19. 5. There were six other residents who were transferred to hospitals and the facility staff failed to provide written notice of transfer/discharge to the resident and the resident representative and failed to document ombudsman notification in the clinical record. Those residents were identified as Resident #267, Resident #83, Resident #36, Resident #115, Resident #19, and Resident #69. The survey team met with the administrator, the director of nursing (DON) and the corporate registered nurse on 1/24/19 at 4:14 p.m. and during the meeting asked what information was provided to the receiving provider when transferred to the hospital. The DON stated the face sheet and the medication administration record were sent. The DON stated the facility does not give the resident and resident representative written notice of transfer/discharge. The DON stated the facility was reviewing a form called Interact for transfers. No further information was provided prior to the exit conference on 1/28/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to provide to the resident and the resident representative at the time of transfer/discharge written notice which specifies the duration of the bed-hold policy for 8 of 29 residents (Resident #104, Resident #83, Resident #90, Resident #36, Resident #115, Resident #218, Resident #25 and Resident #69). The findings included: 1. The facility staff failed to provide Resident #104 and the resident representative written information about bed-hold when the resident was transferred to the hospital 12/19/18. The clinical record of Resident #104 was reviewed 1/23/19 through 1/28/19. Resident #104 was admitted to the facility 12/10/18 and readmitted [DATE] with diagnoses that included but not limited to hypokalemia, dementia with behavioral disturbances, atrial fibrillation, restlessness and agitation, insomnia, infected left femur fracture, metabolic encephalopathy, urinary tract infection, and hypertension. Resident #104's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/9/19 assessed the resident with a brief interview for mental status (BIMS) as 4/15. The departmental note dated 12/19/18 at 2:18 p.m. read in part She is leaving facility at this time for direct admit to RGH (name of hospital omitted). Transported via (name of ambulance service omitted) and two attendants. The departmental notes were reviewed on 1/24/19. The 12/19/18 5:32 p.m. departmental note read, RGH (name of hospital) nurse called and wanted to know why resident was there. She did not get a report from this facility as to why. They do have a bed and she is been admitted (sic) at this time. The clinical record had no documentation that a bed hold was offered to the resident and the resident representative prior to transfer to the hospital on [DATE]. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the nurses usually offer a bed hold when the residents are transferred. The DON was asked if this information should be documented in the clinical record. The DON stated the nurses should document when bed holds are offered in the clinical record. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 1/28/19. 2. The facility staff failed to provide Resident #90 and the resident representative written bed hold information when the resident was transferred to the hospital on [DATE] and 11/4/18. The clinical record of Resident #90 was reviewed 1/23/19 through 1/28/19. Resident #90 was admitted to the facility 3/13/17 and readmitted [DATE] and 11/7/18 with diagnoses that included but not limited to vascular dementia without behavioral disturbances, type 2 diabetes mellitus, hypothyroidism, cervical disc disorder, right femur intertrochanteric fracture, osteoporosis, gastro-esophageal reflux disease, contusion of scalp, chronic diastolic heart failure, cerebral infarction, dysphagia, major depressive disorder, polyneuropathy, anemia, hypertension, and hyperlipidemia. Resident #90's significant change in assessment minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/2/19 assessed the resident with a brief interview for mental status (BIMS) as 7/15. A telephone order dated 10/29/18 read May send resident to ER (emergency room) for eval (evaluation) & treat (treatment). The surveyor reviewed the departmental note dated 10/29/18 10:44 p.m. The note read in part: Late Entry: This nurse was called to therapy gym. Resident was found in floor on right side. Resident stated she had lost her balance and fell to the floor. Upon assessment resident stated she had pain in her right hip and right side of her head on a pain scale of 4 out of 10. Right side of head had hematoma present. Resident was assisted to wheelchair and to her room. MD (medical doctor) notified (name omitted) concerned of resident on Coumadin with the fall and wanted resident to be sent to ER (name omitted). Transport arrived at 1820 (6:20 p.m.) and resident left via stretcher. Departmental note dated 10/30/18 10:44 a.m. read in part Resident admitted to hospital. A second physician order dated 11/4/18 read May send out to ER (name omitted) for eval & tx (treatment) due to increased confusion, combativeness, trying to harm self and decreased O2 (oxygen) sat (saturation). The surveyor reviewed the departmental note dated 11/4/18 6:46 p.m. The note read Late entry 6p.m. Resident noted to have increased confusion with big change in personality. She has been very combative to staff this shift. Resident can normally hold a normal conversation, but cannot at this time. She began doing things to herself, such as, pulling her own hair, bending fingers backwards while looking at staff and stating look here, I'm going to tell them you did this. You are going to be accused of it. This is not normal behavior for this resident. This nurse sent to ER for eval and tx. Physician aware and RP (responsible party) agrees with this nurses decision and is meeting resident at hospital. The clinical record did not have documentation that written notice of bed hold information was provided to the resident and the resident representative when Resident #90 was transferred to the hospital 10/29/18 or 11/4/18. The surveyor informed the director of nursing of the above information not found in the clinical record for either of Resident #90's transfers to the emergency room and subsequent admissions to the hospital on [DATE] and 11/4/18 on 1/27/19 at 3:55 p.m. The director of nursing stated the only information sent with the resident was the face sheet and the medication administration record (MAR). The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the nurses usually offer a bed hold when the residents are transferred. The DON was asked if this information should be documented in the clinical record. The DON stated the nurses should document when bed holds are offered in the clinical record. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 1/28/19. 3. The facility staff failed to provide Resident #218 and the resident representative written information about bed-hold when the resident was transferred to the hospital 11/24/18, 1/4/19, and 1/18/19. The clinical record of Resident #218 was reviewed 1/23/19 through 1/28/19. Resident #218 was admitted to the facility 4/6/18 and readmitted [DATE] with diagnoses that included but not limited to acute osteomyelitis, sepsis, cellulitis of right lower limb and chronic respiratory failure with hypercapnia. Resident #218's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/14/19 assessed the resident with a brief interview for mental status (BIMS) as 15/15. The clinical record revealed three emergency room visits with two requiring hospitalizations. Resident #218 was sent to the emergency room on [DATE] for abdominal pain and constipation. There was documentation that a report was called to the emergency room but no further evidence of what information was provided to the receiving provider or that the resident and the resident representative was offered a bed hold when transferred. The clinical record revealed Resident #218 was admitted to the hospital 1/4/19 as evidenced by the physician discharge summary for 1/4/19-1/7/19. The departmental note dated 1/4/19 at 3:43 a.m. read Resident left facility via wheelchair with son at 3:40 a.m. to go to an appointment. No skin issues or distress noted. The departmental note dated 1/4/19 at 11:44 a.m. read Resident continues to be out of facility. The departmental note dated 1/4/19 at 10:44 p.m. read Resident remains OOF (out of facility) at hospital. None of the notes dated 1/4/19 detail information sent to the receiving provider when the resident did not return to the facility on 1/4/19 or information about bed holds was offered to the resident and the resident representative. The surveyor interviewed Resident #218 on 1/23/19 at 3:37 p.m. The resident stated she thought she was informed about bed-holds. The clinical record revealed Resident #218 was admitted to the hospital 1/18/19-1/21/19 for acute kidney injury. The departmental note dated 1/18/19 at 1:53 p.m. read in part Resident complains of feeling bad. Could not state exactly what her complaints were more specifically. Did state she was having double vision and that her vision was wavey. MD (medical doctor-name omitted) notified. Telephone order received to send patient to ER (emergency room) for evaluation and treatment of complaints. The departmental note dated 1/18/19 at 2:24 p.m. read EMS (emergency medical services) notified for transport to the ED (emergency department), report called to ED (name omitted). The departmental note dated 1/19/19 at 10:32 a.m. read in part Resident was admitted [DATE] for acute kidney injury. The surveyor was unable to locate documentation in the clinical record of bed-hold. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the nurses usually offer a bed hold when the residents are transferred. The DON was asked if this information should be documented in the clinical record. The DON stated the nurses should document when bed holds are offered in the clinical record. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 1/28/19. 4. The facility staff failed to provide Resident #25 and the resident representative written information about bed-hold when the resident was transferred to the hospital 1/11/19. The clinical record of Resident #25 was reviewed 1/23/19 through 1/28/19. Resident #25 was admitted to the facility 2/10/18 and readmitted [DATE] with diagnoses that included but not limited to acute and chronic respiratory failure with hypoxia, hypothyroidism, hypercholesterolemia, major depressive disorder, hypertension, acute bronchitis, repeated falls, hyperlipidemia, pressure ulcer stage 2 right buttock, and discitis. Resident #25's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/21/18 assessed the resident with a brief interview for mental status (BIMS) as 15/15. The clinical record revealed a telephone order dated 1/11/19 that read May send out to ER (emergency room) (name of hospital omitted) for eval (evaluation)/tx (treatment) d/t (due to) fall & c/o (complaints of) pain. The surveyor reviewed the 1/11/19 6:07 p.m. departmental note. The note read in part: @1728 (5:28 p.m.) staff stated that resident was in the floor. Resident was observed to be laying on his left side on the left side of the bed. Blood was coming from resident's head and left forearm. Pressure was held onto (sic) bleeding areas. 911 was called for transport. Resident stated that his left hip, left shoulder and head was hurting. Unable to do neuro checks due to resident's refusal. MD (medical doctor) and RP (responsible party) aware. Rescue squad arrived x3 attendants. Resident was assisted onto the stretcher x3 attendants and 2 employees. Resident left the facility at this time. Report was called to ER (emergency room) (name omitted). The departmental note failed to have evidence of information that Resident #25 bed hold information was offered to the resident and the resident representative. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern during the end of the day meeting on 1/24/19 at 4:14 p.m. The survey team asked what information was provided when residents are transferred to the hospital. The director of nursing stated the face sheet and the medication administration record (MAR). The DON stated the nurses usually offer a bed hold when the residents are transferred. The DON was asked if this information should be documented in the clinical record. The DON stated the nurses should document when bed holds are offered in the clinical record. No further information was provided prior to the exit conference on 1/28/19. 5. There were four other residents who were transferred to hospitals and the facility staff failed to provide written bed hold information to the resident and the resident representative. Those residents were identified as Resident #83, Resident #36, Resident #115, and Resident #69. The survey team met with the administrator, the director of nursing (DON) and the corporate registered nurse on 1/24/19 at 4:14 p.m. and during the meeting asked what information was provided to the receiving provider when transferred to the hospital. The DON stated the face sheet and the medication administration record were sent. The DON stated the nurses usually offer a bed hold when the residents are transferred. The DON was asked if this information should be documented in the clinical record. The DON stated the nurses should document when bed holds are offered in the clinical record. The director of nursing provided the surveyor with the policy titled Bed-Holds and Returns on 1/25/19. The policy read in part Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. No further information was provided prior to the exit conference on 1/28/19.