Oak Park Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a safe and sanitary manner to prevent potential cross-contamination and failed to label and date food items. This had the potential to affect all residents who consumed food from the facility kitchen, The facility had a census of 85. Review of the facility Food Storage Policy, dated 3/31/21, revised on 8/16/23, showed: -Policy: Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety; -Responsibility: Dietary Aide, Dietary Cook, & Dietary Manager; -Dating of leftovers shall be as follows: -Multiple ingredients shall be used the same day of preparation then discarded; -Other potentially hazardous leftovers shall be labeled with an expiration date of three (3) days; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) for three residents (Residents #57, #29 and #82). Furthermore, the facility failed to follow their incontinent care policy when staff provided perineal area care (cleansing between the legs and buttocks area) to Resident #82. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity when one resident's (Resident #90's) catheter bag (urine drainage bag) was visible to the hallway from the resident's room. In addition, staff fed one resident (Resident #43) while standing over the resident during a meal. The sample size was 18. The census was 85. Review of the facility's Resident Rights policy, reviewed 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect and dignity and ensure resident right are being followed. The resident/resident representative will be informed on their rights upon admission; -Procedure: Employees will receive education and training on resident rights upon hire and annually; -Resident Rights included: -Exercise Rights; -Respect and Dignity; -Privacy and confidentiality. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy when one resident (Resident #29) fell on the facility's transport van while returning from a doctor's appointment and staff moved the resident without a nurse physically assessing the resident or calling 911. The census was 85. Review of the facility's Fall Management Policy, dated 2/28/23, showed: -Definition: fall is a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object; -Prevention/treatment: Prior to moving the resident, the charge nurse will evaluate for injury. Review of Resident #29's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/14/24, showed: -Moderately impaired cognition; -Dependent on staff for rolling left to right; -Dependent on staff for chair/bed to chair transfer; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified four medication carts, two nurse's carts, one treatment cart, and one medication room. Of those medication storage areas, three medication carts, one nurse's cart, and one medication room was reviewed. Issues were found in one medication cart and one nurse cart. A carton of Ensure Plus nutrition shake was opened and undated. A tube of Venelex ointment (used on the skin to cover wounds) and a tube of Betamethasone cream (used to help relieve redness, itching, swelling, or other discomforts caused by certain skin conditions) were opened, undated and unlabeled. The census was 85. Review of the facility's Medication Storage Policy, dated 11/2018, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate administration of water flushes and enteral nutrition for one resident who was dependent upon a gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) for nutrition and hydration for one residents (Resident #1). Resident #1 was admitted to the facility on [DATE]. admission orders showed Nepro (balanced, high-calorie nutrition) 50 milliliters (ml)/hour via g-tube continuously and water flushes 180 ml every four hours. On 3/5/24, the order was changed to Glucerna (calorically dense formula) due to the unavailability of Nepro. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make an appointment with a surgeon for one resident with wounds on his/her fingers on both of his/her hands. The wound care company's physician requested a consult with a surgeon on 11/30/23, due to exposed bone on some of the resident's fingers. Facility staff failed to make the surgeon's appointment for the resident until 1/10/24 (Resident #5). The census was 86. Review of the facility's Wound Management policy, dated 11/15/22, included: -Policy: To promote wound healing of various types of wounds, the facility will provide evidenced based treatments in accordance with current standards of practice and physician orders; -Procedure: -Wound Management: -Wound treatment will be provided in accordance with physician order: cleansing method, type of dressing, frequency of dressing change; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed their Wound Management Policy, failed to follow and/or promptly follow new and/or altered treatments and discontinued treatments as ordered by the wound care company physician for one resident with pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the left heel, right heel, sacrum (the bony area between the lower back and upper buttocks) and right lateral ankle. (Resident #10). The facility also failed to ensure one resident with a care plan intervention to wear a heel protector while in bed, and an order from the wound care company to wear off-loading boots, wore those pressure relieving devices. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with an order for an indwelling urinary catheter (thin tube inserted through the urethra and into the bladder to drain the bladder of urine) had the size of catheter as ordered on the physician's order sheet (POS). In addition, the facility failed to ensure the resident's catheter bag (used to collect the urine and is attached to the catheter by catheter tubing) remained below the resident's bladder during a Hoyer lift (a machine used to transfer a resident that is unable to bear weight) transfer, and the catheter bag remained off the floor. The facility identified two residents with catheters, one was sampled (Resident #3) and problems were identified. The census was 86. Review of the facility's Catheter Care policy, dated 7/13/22, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with a clean, comfortable and homelike environment by not ensuring two resident rooms, bathroom and the dining room were clean and in good repair (Residents #67 and #27). The census was 82 1. Observation on 1/22/23 at 12:04 P.M., of the main dining room, showed approximately 3 feet of plastic baseboard, loosened from the wall under the dining room windows. Parts of the baseboard lay on the floor. The wall behind the baseboard appeared torn, dirty and in disrepair. 2. Review of Resident #67's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/22, showed: -Responds adequately to simple, direct communication; -Requires one person physical assistance in toilet use, dressing and personal hygiene; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive the necessary services to maintain good personal hygiene for two residents observed during perineal care (cleansing of the area between the legs to include the buttocks and genitals) who were left soiled for an extended period of time and then not completely cleaned (Residents #83 and #46). The facility also failed to ensure weekly showers were provided and hair cleansed for two residents (Resident #5 and Resident #67). The sample was 18. The census was 82. Review of the incontinent care policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care; -Procedure: Explain procedure to the resident. Perform hand hygiene and apply gloves. Removed soiled brief. Cleanse the peri-area. -For females: [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 82. Review of the facility's Facility Assessment Tool, updated 1/5/23, showed: -Average daily census: 80; -Staffing type/plan: Administrator, RN, licensed practical nurses (LPNs), and certified nurse aides (CNAs); -Position: Licensed nurses providing direct care (RN or LPN): 7; -CNAs: 20; -Other nursing personnel: 3; -How did the facility assess the resident population: Point Click Care (PCC, electronic medical record), Minimum Data Set (MDS), and Quality Assurance and Performance Improvement Plan (QAPI); -Does this reflect the population observed: yes; -How did the facility determine the staffing level: Census vs acuity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete the controlled substance inventory sheets appropriately to maintain accurate accountability of the inventory of all controlled substances administered at all times. The facility had incomplete controlled substance sheets for three of six narcotic count sheets sampled. The sample size was 18. The census was 82. Review of the Controlled Substance Storage policy, dated 2/2020, showed: -Policy: Controlled substances are subject to special handling, storage, disposal and record keeping in the facility; -Procedures: -The Director of Nursing (DON), in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly medication reviews (MMR) were completed timely (Residents #6, #17, #31, #44 and #47). The facility also failed to complete the physician's order to consult psychotherapy services following a gradual dose reduction (GDR) recommendation in December 2022 (Resident #47). The sample was 18. The census was 82. Review of the facility's Medication Regimen Review (MRR) policy, dated 12/2017, showed: -Policy: The AlixaRx clinical pharmacist (ACP) performs a comprehensive review of each resident's medical record at least monthly. Irregularities, findings, and recommendations are reported at a minimum to the Director of Nursing (DON), attending physician, and the Medical Director; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident exposed during personal hygiene after staff left the resident's room door open to the hallway and the bedroom curtains open to the parking lot (Resident #46). Staff left a resident exposed in his/her brief in the wheelchair and also spoke to him/her in a disrespectful manner when the resident notified the staff of a high blood sugar level (Resident #37) The sample size was 18. The census was 82. Review of the incontinence care policy, dated 7/21/22, showed to provide privacy, close the door and the curtains and or the blinds. 1. Review of Resident #46's quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 10/6/22, showed: -Severe cognitive impairment; [...]

Inspectors wroteBased on interview and record review, the facility failed to refund resident funds within 30 days of discharge for one resident (Resident #133). The sample was 18. The census was 82. 1. Review of Resident #133's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/22, showed: -Entry date: 8/16/21; -Unplanned discharge; -Discharge assessment: return anticipated; -Discharge status: acute hospital. Review of the resident's admission/discharge/death to social security form, dated 9/20/22, showed the resident discharged on 7/9/22. Review of the resident's progress notes, showed on 8/22/22 at 5:54 P.M., call placed to hospital to get update on resident's condition. Spoke to nurse who states the resident remains in Intensive Care Unit (ICU) on ventilator and meeting has been scheduled for possible trachea placement. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all physician orders were followed by not ensuring the order for a magnetic resonance imaging (MRI, procedure that make detailed pictures of areas inside the body) was completed (Resident #70), not ensuring pressure relieving boots were worn as ordered (Resident #36) and diet orders were followed as ordered (Residents #36 and #44), for three of 18 sampled residents. The census was 82. Review of the facility's physician's orders policy, dated 9/28/22, showed: -Policy: To provide guidance and ensure physician's orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Procedure: Physician orders shall be provided by licensed practitioners authorized to prescribe orders; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge planning process was in place which addressed discharge goals and needs, including caregiver support, referrals to local contact agencies as appropriate and involvement with the resident for one of two residents sampled for discharge planning (Resident #70). The census was 82. Review of the facility's discharge plan/summary policy, reviewed 10/7/21, showed: -Policy: An interdisciplinary summary is competed on a resident upon discharge to assure the continuum care needs of the resident are met; -A physician order must be obtained; -Upon notification of impending discharge, the interdisciplinary team should be notified to allow staff the opportunity to educate and implement a safe discharge. Social work should coordinate the discharge planning process; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain perimeters for a blood sugar over 350 for one sampled resident (Resident #37) and failed to update the resident's care plan. In addition, the facility failed to ensure the Glucagon (medication to treat low blood sugar levels) kit was assessable to all nursing staff. The resident sample was 18. The census was 82. During an interview on 1/23/23 at 12:15 P.M., Corporate Nurse A said the facility did not have a policy for insulin administration. Review of Resident #37's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/22, showed: -Cognitively intact; -Diagnoses included diabetes, hyponatremia (low sodium in the blood), and hyperlipidemia (high level of lipids in the blood); -Insulin injections administered in the last seven days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to maintain or improve mobility when staff did not provide range of motion for one resident or a restorative therapy (RT) program for a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) prevention and treatment (Resident #60). The facility census was 82. Review of the undated referral to the restorative program policy, showed: -Policy: The restorative team promotes the highest level of functioning in areas of self-care, cognition, communication and mobility; -Procedure: Nursing rehabilitation or other staff may provide restorative referrals for the restorative program when: -A decline in function of a resident is noted, per nursing documentation; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper positioning of the resident's indwelling catheter (a thin tube inserted through the urethra into the bladder to drain urine) tubing and catheter drainage bag for one resident (Resident #18). The facility failed to ensure there were current physician orders for the indwelling urinary catheter. Facility staff also failed to address the catheter use on the resident's care plan. The facility identified one resident with an indwelling urinary catheter (Resident #18). The census was 82. Review of the facility's catheter care policy, dated 7/13/22, showed the facility will maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention of infection or complications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were not kept past their expiration dates and that medications for residents who were no longer in the facility were removed from the active medication supply for one of one medication room. The facility identified having one medication room, four medication carts and one treatment cart. The census was 82. Review of the facility's Medication Storage in the Facility policy, revised 11/2018, showed: -Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to offer special dietary equipment per the resident's plan of care to assist each resident to maintain their highest level of function and independence, for one resident (Resident #36). The sample was 18. The census was 82. Review of Resident #36 Care Plan, in use at the time of survey, showed: -Problem: Resident needs help with activities of daily living (ADLs) due to a stroke; -Outcome: Resident's needs will be met with assist of staff; -Interventions: Resident will have built up dietary utensils at meals. Divided plate at meals. Lid cup with straw. Review of the Resident's Meal ticket, showed: -Breakfast: Regular diet, thin liquids, dislikes milk; -Adaptive equipment: built-up utensil handles, divided plate, lidded cup with straw; -Standing order: double eggs; -Lunch: Regular diet, thin liquids, dislikes milk; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection control during personal care for two residents (Resident #46 and Resident #83). Staff failed to change their gloves or sanitize their hands after touching soiled surfaces, prior to touching the resident and his/her personal items. Staff also placed soiled linens directly onto the resident's floor. The sample was 18. The census was 82. Review of the Facility's Incontinent Care policy, dated 7/21/22, showed: -Policy: The facility will provide incontinent care as directed in the plan of care; -Procedure: Explain procedure to the resident. Perform hand hygiene and apply gloves. Removed soiled brief. Cleanse the perineal area (the surface area between the thighs, extending from the pubic bone to the tail bone); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' call light system was working properly and ensure that the call light was in reach for two of 18 sampled residents (Residents #31 and #37). The census was 82. Review of the facility's Resident Call System Policy, dated 10/20/22, showed the following: -Policy: The facility call system relays calls directly to a centralized work area from the resident's bedside, toilet, and bathing area. The call system is accessible to a resident lying on the floor as required by state/federal guidelines; -Responsibility: Nursing, Interdisciplinary Team (IDT) Members, Maintenance Director, and Licensed Nursing Home Administrator (LNHA); -Procedure: -Upon admission nursing will orientate resident to accessing the resident call system; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a corridor in one hall was completely equipped with handrails. This practice potentially affected any residents who reside in or use this area in the facility. The census was 82. Observation on 1/22/23 at 9:15 A.M., showed the handrail in between the men's shower and room [ROOM NUMBER], a whole piece of handrail was missing. The three braces and screws, where the handrail was supposed to be hung, were still attached to the wall. During an interview on 1/22/23 at 10:01 A.M., Certified Nurse Assistant (CNA) Q said the handrail by room [ROOM NUMBER] has been missing for months. He/She said there was no handrail in that area when he/she was employed in September 2022. He/She said the maintenance staff were aware of the issue. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. In addition, the facility failed to properly document narcotic counts for the controlled substances on one of four medication carts. The facility census was 87. 1. Review of the Certified Medication Technician's (CMT)'s narcotic count sheet, dated 6/1 through 7/18/19, for the 100 and 200 Halls, showed the following: -No signature by the on-coming staff, a total of 26 shifts; -No signature by the off-going staff, a total of 33 shifts; -Narcotic count not recorded or signed by the on-coming or off-going staff, a total of 13 shifts. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignity to residents by not providing dining assistance to one visually impaired resident (Resident #40), failed to assist a resident with wet soiled clothing (Resident #8), failing to treat a wound and allowing the drainage from that wound to remain visible on the wall (Resident #14) and by placing a resident who could not eat among a group of others who were enjoying an ice cream treat (Resident #69). The sample size was 18. The census was 87. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/10/19, showed the following: -Severe cognitive impairment; -Unable to ambulate; -Extensive assistance to total dependence on staff for all mobility and personal care; -Supervision with eating; -Severely impaired vision; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a facility code status (full code-if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate, no life prolonging methods are performed) form for one resident (Resident #77), failed to obtain a physician's order for code status for one resident (Resident #6) and failed to perform a yearly review to verify the code status for two residents (Residents #10 and #14). These practices affected four out of 18 sampled residents. The census was 87. 1. Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/19, showed the following: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease and malnutrition. Review of the medical record, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain records of residents' personal possessions. Furthermore, the facility failed to address the process to maintain personal property inventory sheets in the facility's admission agreement. A review of 18 sampled residents, showed nine residents did not have documentation of their personal possessions in their medical records (Residents #39, #10, #57, #28, #14, #69, #238, #63 and #1). The census was 87. 1. Review of the facility's admission Agreement, undated, showed the facility did not address how they would document and maintain personal property inventory sheets. 2. Review of Resident #39's medical record, showed the following: -admitted to the facility on [DATE]; -A personal property inventory sheet, dated 10/24/13; -No updated personal inventory sheet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and ensure nail care, including cleansing and trimming had been completed and provide proper grooming for facial hair for four of 18 sampled residents (Residents #84, #21, #59 and #40). The census was 87. 1. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/19, showed the following: -Moderate cognitive impairment; -Dependent on staff for personal hygiene; -Diagnoses included dementia, Parkinson's disease (a neurological condition that causes muscle rigidity, tremors, and changes in speech and gait) and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). Review of the care plan, dated 4/3/19, showed the following: -Problem: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs by failing to obtain qualifying diagnoses for the use of antipsychotic medications for three of 18 residents sampled (Residents #77, #63 and #1). The census was 87. 1. Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/19, showed the following: -admitted to the facility on [DATE] with a readmission date of 11/16/18; -Severe cognitive impairment; -Unable to ambulate; -Extensive to total dependence on staff for all care; -Received an antipsychotic and antidepressant the last seven of seven days; -Diagnoses included Alzheimer's disease and malnutrition. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement person-centered comprehensive care plans to meet preferences and goals and address residents' medical, physical, mental and psychosocial needs, by not addressing a resident's behavioral needs (Resident #63) or address a resident's discharge goals (Resident #1). The census was 87. 1. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/18/19, showed the following: -Moderate cognitive impairment; -No behaviors; -Extensive assistance from staff for toileting, hygiene, dressing and transfers; -Diagnoses included high blood pressure, depression, diabetes and bipolar disorder (unusual shifts in mood). Review of the resident's medical record, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to summarize the stay for one of the two discharged residents' records reviewed (Resident #87). The staff did not write a discharge note or indicate what information they provided to the resident and to the receiving facility. The census was 87. 1. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/2/19, showed the following: -Moderate cognitive impairment; -Limited assistance required for personal hygiene; -Independent with all mobility; -Continent of bowel and bladder; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one resident (Resident #84) by not recognizing a weight loss of 9.02% over a period of three months and not ensuring the resident received an evaluation by a registered dietician. The sample size was 18. The census was 87. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/19, showed the following: -Moderate cognitive impairment; -Extensive assistance required for all mobility, eating and toileting; -Dependent on staff for personal hygiene; [...]

Inspectors wroteBased on observation and interview, the facility failed to post the required nurse staffing information, which included the actual hours worked by both licensed and non-licensed nursing staff directly responsible for resident care, per shift on a daily basis, for five of five days of observation. The census was 87. Observations on 7/16/19 at 10:00 A.M., 7/17/19 at 9:44 A.M., 7/18/19 at 8:24 A.M. and 1:00 P.M., 7/19/19 at 8:15 A.M. and 7/22/19 at 10:00 A.M., of the daily nursing staffing information sheet, posted outside of the business office, did not contain the actual hours worked by both licensed and non-licensed nursing staff per shift directly responsible for resident care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written transfer/discharge notices to residents or their legal representatives for two of 18 sampled residents who were transferred to the hospital for medical reasons (Residents #63 and #238). The census was 87. 1. Review of Resident #63's Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed the following: -discharged to the hospital on 6/27/19; -Returned to the facility from the hospital on 7/2/19; -No documentation the resident and/or their representative received written notice of the resident's transfer. 2. Review of Resident #238's MDS admission and discharge assessments, showed the following: -discharged to the hospital on 7/9/19; -Returned to the facility from the hospital on 7/13/19; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice to the resident or their legal representative, of the facility bed hold policy at the time of the transfer to the hospital, for three of 18 sampled residents, who were recently transferred to the hospital for various medical reasons (Residents #54, #63 and #238). The census was 87. Review of the facility's Bed Hold Policy, last revised March 2017, included the following: -Facility shall inform residents and/or resident representatives upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed hold policy; -Upon a resident being transferred for hospitalization or for a therapeutic leave, the resident and resident representative will be provided information on the facility bed hold policy within 24 hours of the hospitalization or therapeutic leave; [...]