**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a safe and effective discharge planning process for three (#8, #3, and #1) of five residents sampled for discharge. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for dialysis or home health services. Resident #3 had severe cognitive impairment and was discharged in a taxi cab to live with a family member who was not present or prepared to care for the resident in the home. Resident #3 had no way to access the home upon his arrival and the taxi cab driver contacted law enforcement for assistance. Resident #1, who was dependent on oxygen, was discharged home without medical equipment to maintain her respiratory status. The facility's system failure placed Resident #8, Resident #3, and Resident #1 at serious risk of injury or death and resulted in the determination of Immediate Jeopardy on 09/23/2023. The findings of Immediate Jeopardy were determined to be removed on 11/02/2023 and the severity and scope was reduced to an E after verification of removal of immediacy of harm. Findings included: 1) Resident #8 was admitted to the facility on [DATE] with diagnoses to include unspecified sequelae of cerebral infarction, chronic pain, abnormalities of gait and mobility, muscle weakness, End Stage Renal Disease (ESRD) requiring dialysis, temporary catheter in upper right chest for dialysis, altered mental status and adult failure to thrive. A review of the MDS (Minimum Data Set) admission assessment dated [DATE] revealed the resident was able to make himself understood and he was able to understand others. The resident's BIMS (Brief Interview for Mental Status) score was 11, indicating moderately impaired cognition. In Section G: Functional Abilities, the resident was assessed as requiring extensive assistance with one staff for toileting, personal hygiene, and dressing; supervision with one staff for walking in his room or for short distances, with his balance described as unsteady. A review of the resident's care plan, dated 09/26/2023, revealed the following: Problem: discharge: Resident has D/C (discharge) plan, is uncertain at this time as he lost his home in the community. (start date 09/26/2023) Goal: Resident will receive assistance with discharge planning should preferences change through the review date. (Long term goal target date: 12/26/2023) Approaches included: Ask about returning to the community with each assessment. Re-evaluate preferences regarding discharge planning regularly and PRN (as necessary). (Start date: 09/26/2023) Problem: Nutritional Status: Resident is at nutritional risk r/t (related to ): ESRD, new dialysis, hx (history) CVA (Cerebral Vascular Accident). (Start date: 09/27/2023) Goal: Resident's weight will remain less than +/- 5% weight change within a 30 day time period through next review. (Long term goal target date: 12/27/2023) Approaches included: Monitor lab values per dialysis record Albumin >60 yr: 3.4 - 4.8 g/dl (grams per deciliter); plasma transferrin> 60 yr: 180-380 g/dl; HGB (hemoglobin) - Males: 14-17 g/dl - Females: 12 - 15 g/dl; HCT (hematocrit) - Males 41-53 - Females 36-46; Potassium: 3.5 5.0 mEq/L (milli-Equivalents/Liter); Magnesium: 1.3 - 2.0 mEq/L). Resident will attend dialysis as scheduled T, Th, Sat (Tuesday, Thursday, Saturday). Resident will receive a NAS (no added salt diet), avoid potatoes, tomatoes, bananas, oranges r/t high K (potassium) content. Weigh and monitor results upon admission daily times 3 days, weekly x 4 weeks, then monthly if stable. (Start Date: 09/27/2023). A review of the Transition of Care/Discharge summary, dated [DATE], revealed Resident #8 would be returning to his home. The document showed the resident was responsible for himself. The Discharge Summary did not include a contact phone number for either the resident or an emergency contact. The summary did not include the ESRD facility address and his schedule to receive dialysis. Under the heading of Care Plan Goals, as a discharge goal, the facility had documented, PT (Physical Therapy), OT (Occupational Therapy) , RN (Registered Nurse) Eval (Evaluation). There was no reference to the referral for a Home Health Agency or who would be conducting the evaluations. The summary did not contain a Post Discharge Plan of Care which would include: arrangements that have been made for follow up care and services; how the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed in accordance with the facility's undated policy titled Discharge Summary and Plan. Review of the Social Services Director (SSD) progress note dated 10/05/2023 revealed a referral had been made to a Home Health Agency. A telephone interview was conducted with the Home Health Agency on 10/19/2023 at 11:08 a.m. to ask about services ordered for Resident #8. The Referral Intake Associate at the Home Health Agency reported they did not have Resident #8 in their system to provide home health services following his discharge on [DATE]. The Referral Intake Associate confirmed they made no visits to Resident #8 after he was discharged from the facility on 10/06/2023 and no PT, OT, or RN services had been rendered. A review of the Therapy Discharge Summary for Physical Therapy services provided from 9/20/2023 - 10/05/2023 for Resident #8 revealed the patient was unable to make significant functional gains due to being dialysis dependent and fatigued post dialysis. The discharge instructions included the resident's need for assistance with all ADLs. A review of Resident #8's progress notes revealed: -admission note, dated 09/19/2023: The resident was alert, verbalizing appropriately, tearful at times and stated he was unsure of dialysis. -Social Services Director (SSD) note, dated 09/20/2023: The resident appeared alert and oriented x 3, with a plan of discharge to remain in the facility long term care for now. The note included the resident's statement of feeling depressed with the SSD noting she would refer the resident to the psychologist. -An IDT (Interdisciplinary team) note, on 09/26/2023, documented a continued need for a skilled level of care and continued work with therapy. The note indicated the discharge plan was uncertain at this time as he lost his home in the community. -10/02/2023 a note by the SSD indicated the plan for discharge was to go out of state to Indiana. -10/04/2023 the resident was presented with a Notice of Medicare Non-Coverage (NOMNC) showing the LCD (last covered day) of Medicare coverage to the facility was 10/05/23 and the resident chose not to appeal this decision. - SSD note, dated 10/05/2023: The resident would be going home to the address noted on his face sheet from admission and a name and address for the Home Health Agency was listed. -10/06/2023 a nurse's note confirmed the resident had been discharged to home by taxi. - Progress note, dated 10/09/2023 at 1:00 p.m., revealed the Administrator received a call from the Social Worker at the Dialysis center where Resident #8 had been receiving services. The Social Worker asked the Administrator why they discharged the resident to a condemned trailer and apprised the Administrator the resident had missed his last dialysis treatment, on 10/07/2023. The Administrator told the Dialysis Social Worker the facility was not aware the resident's home was condemned and didn't know he had skipped dialysis the day after he was discharged home. The Administrator explained to the Dialysis Social Worker, as documented in her progress note written on 10/09/2023, she had met with the resident with the facility SSD to explain to the resident he was welcome to remain at the facility during the Medicaid pending process. The Administrator documented the resident informing her and the SSD he wanted to return home and showed both of them he had his keys to his home to let himself back in. After the phone call, the Administrator and the facility SSD drove over to the resident's home and saw the home was a trailer that generally was in good repair, but had two windows broken out. The resident was sitting outside of the trailer and told the facility staff his neighbors were working on fixing up the trailer for him. After receiving permission, the SSD looked inside of Resident #8's trailer and documented garbage, filth, a horrible odor, and a piece of orange paper in the doorway. The orange paper was a condemned notice. When the facility staff told Resident #8, he could not remain living in a condemned trailer he became verbally abusive. The facility staff phoned 911 and the police officer who responded told the resident he could not remain in a condemned trailer and if he did, he was trespassing. When the officer offered the resident three choices --going to the hospital, jail, or returning with the facility staff to the facility, he chose to return to the facility. Upon returning to the facility the resident was evaluated by Psychiatric services who determined the resident was a danger to himself and he was involuntarily admitted to the hospital. An interview was conducted with the NHA (Nursing Home Administrator) and the SSD on 10/17/2023 at 5:00 p.m. The NHA reported they were not aware the trailer had been condemned and didn't know why the Home Health Agency hadn't called them to let them know the resident's trailer was condemned. The NHA said the resident told them his home was ok, he showed them his keys indicating he would be able to get into the trailer, and he could discharge to his home. The SSD reported she just hadn't revised the care plan to indicate he had a home in the community. They confirmed they had not investigated the home and the condition of the home. They confirmed they discharged the resident as he requested and had not followed up on the resident's statement that he lost his home in the community as documented in the 09/26/2023 care plan and IDT progress note. A call was placed to the Dialysis Social Worker on 11/02/2023 at 3:10 p.m. She confirmed the dialysis facility had not been notified of the resident's discharge from the nursing home to his mobile home. She stated she would have questioned that discharge as she was aware the mobile home had been condemned. She stated she knew about the trailer from his initial hospitalization paperwork, which led to his transfer into the nursing home. She reported the resident had been receiving dialysis at her facility for a year or two and agreed the address and schedule should have been on his discharge paperwork for him due to his fluctuating cognition. Resident #8 was re-admitted to the facility on [DATE] from the hospital. On 11/02/2023 at 9:00 a.m. an interview was conducted with Resident #8. He stated he was found at his mobile home by the lady in charge (NHA), was taken back to the hospital (for an involuntary admission), and then came here (back to the facility). He confirmed he received dialysis services and touched the dressing on his catheter located in his upper right chest, then held up his right arm to expose his new permanent vascular access for dialysis. He wasn't sure if he had gone to dialysis. He said he felt ok and didn't think he needed to go. When asked if he went to dialysis when he was discharged home on [DATE], he stated he hadn't been told the address or the schedule for his dialysis treatments when he was sent home so he had not gone. 2) Resident #3 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization with diagnoses to include senile degeneration of brain, altered mental status, vascular dementia, severe with agitation, schizophrenia, and major depressive disorder. A review of the 08/01/2023 admission Minimum Data Set (MDS) Assessment, Section C: Cognitive Abilities, showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident's mental status was described as inattentive with disorganized thinking. In Section G: Functional Abilities, the resident was assessed as needing extensive assistance with two staff for bed mobility, transferring, and toileting; extensive assistance with one staff for locomotion around the facility in a wheelchair, dressing, eating, and personal hygiene; and his gait was not steady. A review of the care plan, dated 08/18/2023, revealed the following: Problem: discharge: Resident has chosen to discharge home with family. Plan to return to community or other care setting at this time. (Start Date: 08/18/2023) Goal: Resident will receive assistance with discharge planning should his preferences change through the review date. (Long Term Goal Target Date: 11/14/2023) Approaches included: Resident preferences regarding his discharge planning regularly and PRN (as necessary). (Start Date: 08/18/2023) A review of progress notes for Resident #3 revealed the following: -Nurses admission note, dated 07/27/2023, revealed the resident required total assistance for his Activities of Daily Living (ADL), but he was able to feed himself after staff set up the meal and provided cueing during the meal. The resident was described as alert and oriented to himself and able to answer simple yes and no questions. -On 07/28/2023 at 1:52 p.m., the SSD documented she attempted to contact the resident's next of kin several times but got no answer, so she left a voice mail. -Nurses notes from 07/28/2023 through to 08/08/2023 continued to document the resident as alert and oriented x 2, able to understand and follow simple commands, without any signs or symptoms of distress. -A note labeled IDT (Interdisciplinary Team) documented on 07/31/2023 staff had tried to contact the family but was unable to make contact and left a message. -On 08/08/2023 at 1:23 p.m., an IDT note documented the resident under skilled level of care, receiving physical and occupation therapy, making minimal progress as his cognition was a barrier to progress. There was to be a new review date by the insurance company on 08/15/2023 and the D/C (discharge) plan was to d/c home with a family member. -On 08/11/2023 the IDT note documented an attempt to make contact with the resident's family member to provide an update on the resident but was unable to make contact with the family and a message was left. -On 08/13/2023 a nurse's note revealed the resident was alert with noted confusion, not able to make his needs known to staff but understood simple commands. -On 08/15/2023 the IDT weekly review described the resident as making slow progress toward therapy goals, he remained a fall risk as he frequently attempted to get up from the wheelchair unassisted and was difficult to redirect due to impaired cognition. He remained at moderate nutritional risk and was followed by the RD (Registered Dietitian). He remained appropriate for skilled level of care. -On 08/21/2023 a nurse documented the resident as alert and oriented x 3, with periods of confusion, but able to make his needs known. He required the assistance of one staff with ADLs, stand by assistance for transfers, and he was incontinent of bowel and bladder. -On 08/22/2023 the IDT documented the resident continued to require a skilled level of care and was receiving therapy. An insurance update had been sent with the outcome pending. His discharge plan remained to discharge home with family. -On 08/29/2023 the facility attempted to contact the family and left a voice mail with an update on the resident. -On 09/05/2023 an IDT note revealed the resident continued at a skilled level of care and was working with therapy. The note showed he was making progress toward his goals. His cognition remained a barrier to his safe discharge. His discharge plan was home with family when all of his goals were met. -On 09/12/2023, at the weekly IDT meeting, the note revealed the resident continued to require a skilled level of care with therapy. His impaired cognition remained a barrier to a higher level of safety. His discharge plan was to go home with family. A new review date for his insurance was 09/15/2023 with the insurance company asking the facility to prepare the resident and family for discharge. -On 09/12/2023 the SSD (Social Services Director) contacted the resident's family to inform them the resident would be discharged after 09/15/2023. She received no answer and left a voice mail. -On 09/14/2023 the SSD documented a note showing it was her third attempt to contact the resident's family about an insurance review and documented her desire to discuss a safe discharge with them. There was no answer, and she left a message, but received no response. -On 09/18/2023 the IDT documented the resident propelling up and down the hallways with attempts to transfer himself without assistance. The note documented the resident was not strong enough to do so and would remain at risk for falls. He continued to work with therapy services to increase his strength. -Later that day, on 09/18/2023, the nurse documented the patient remained severely confused to time and environment. He was not able to make his needs known. He was cooperative with taking medication. He continued to throw himself on the floor numerous times throughout the shift and was seen scooting across the floor several times during the shift. The physician had been made aware of the behaviors and Ativan (as needed) was given but not effective. -On 09/20/2023 the SSD documented the resident's Power of Attorney (POA) had been informed of the resident's NOMNC letter, but he refused to sign the letter. -On 09/20/2023 the SSD documented her visit, with the Maintenance Director to the resident's home to inform the family the resident's last covered day would be 09/22/2023 with a discharge home on [DATE]. Her note revealed several unsuccessful attempts at contacting the family by phone, therefore she felt an in-person visit was necessary. She documented the family had refused to sign the NOMNC letter so the resident would be discharged . -On 09/23/2023 at 8:20 a.m., the SSD documented the family had been informed of the resident's discharge and transported home by a cab service. In an interview with the Administrator and the SSD, on 10/17/2023 beginning at 3:30 p.m., the SSD stated due to the family member not responding to phone calls, she went to the home with the facility's Maintenance Director on 09/20/2023 to discuss the NOMNC document and the resident's potential discharge. She reported the family member answered the door and after the SSD explained the NOMNC and applying for Medicaid so Resident #3 could remain at the facility, the family member said no. The family member would not sign the NOMNC and was not interested in applying for Medicaid. The SSD reported during the visit, the family member opened the garage door to the home to show them that work was being done inside the garage to accommodate the resident upon his return. The family member said the work wasn't done yet so he wasn't ready for the resident to return to the home. The SSD reported that because she and the Maintenance Director had spoken with the family member on 09/20/2023 about the resident's plans to return home on [DATE], and the resident would have discharge documents for the family to reference upon his return, she sent the resident home alone in a taxi cab. The SSD reported the family member said they were expecting the resident back and they would provide the care. A telephone interview with Resident #3's family member on 11/07/2023 at 10:30 a.m. revealed he called the facility on 09/22/2023 around 3:00 p.m. and spoke with an unknown staff member to request for the resident to remain in the facility for another week. He said he told the staff member he would come in on Monday, 09/25/2023, to pay privately for the extra time. The family member stated they must not have received his message because they sent Resident #3 out the next day. The family member confirmed he did not sign the NOMNC because he wasn't going to appeal the decision. He was told the resident had to leave the facility or pay privately and that was what he was going to do. The family member confirmed he was not ready for the resident to return on 09/23/2023 because the construction was not completed. A review of the Transition of Care/Discharge Summary report, dated 09/23/2023, revealed the resident was not identified as being responsible for himself. Under the heading of Special Instructions, therapy had documented: Pt (patient) has been receiving skilled PT/OT since admission at this facility. Pt reached max (maximum) potential and is unsafe to ambulate by himself. Pt is WC (wheelchair) bound and is independent with WC mobility within the facility. Pt recommended continued use of WC upon DC (discharge) for safe mobility. The Home Health Agency company was to provide the wheelchair. The summary did not contain a Post Discharge Plan of Care which would include: arrangements that have been made for follow up care and services; how the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed in accordance with the facility's undated policy titled Discharge Summary and Plan. A review of the Therapy Discharge Summary for Physical and Occupational Therapy services provided from 7/26/2023 - 9/22/2023 showed: The Physical Therapist documented the resident's inability to make significant functional gain which was limited by poor cognition and the inability to learn new information. The resident was able to transfer and ambulate with minimal assistance. The Discharge recommendations from the Physical Therapist was for 24 hour care. The Occupational Therapist documented the resident's progress was hindered by cognitive deficits. The recommendation stated the family should assist with personal and domestic tasks. A review of a local law enforcement report, dated 09/23/2023, revealed the cab driver who took Resident #3 to his home from the facility notified the police of the resident's inability to enter his home. The police officer notified the facility the resident was sitting outside of his home without the ability to enter the home. The police officer had the resident taken to the local hospital where he was admitted . A review of the hospital records dated 09/23/23 at 1:31 p.m. described the resident as having a history of dementia and presenting to the emergency room due to homelessness. The resident's history was obtained from the paramedics as the resident presented with dementia. The note included the resident's recent stay at the facility where his insurance ran out. The facility, according to the hospital note, had tried to get in touch with the family but were unsuccessful and ultimately put the resident into a cab. The cab took the resident to an address listed on the resident's contact sheet. The note described the cab driver's reluctance to leave the resident at a home that did not appear to be lived in. Attempts by the hospital to contact the family were unsuccessful as well. Resident #3 remained at the hospital for a few days prior to being discharged to another long-term care facility. An interview was conducted with the Nursing Home Administrator (NHA) and the SSD on 10/17/23 at 3:30 p.m. The NHA stated the facility had not received return phone calls from the family about Resident #3's stay or his pending discharge. Neither facility staff could remember whether the family had ever visited the resident at the nursing home. They stated a family member had met with the Business Office staff (which is in a different building from the nursing home) to discuss the NOMNC and possibly apply for Medicare. The NHA stated she was not aware of the family member coming into the facility to visit with the resident after being at the Business Office. The Administrator and the SSD stated looking back, this was not a safe discharge. An interview was conducted with the Director of Rehabilitation (DOR) Services on 11/01/2023 beginning at 12:30 p.m. The DOR confirmed she had worked with Resident #3 for the two months that he had been in the facility. She reported that he had not done well in therapy and actually had regressed in his skills. She said it was due to his decline in mental capacity. She confirmed she attended the Interdisciplinary meetings and had expressed her concern with the discharge plan to live at home with the family. She said she told the team, the resident needed 24 hour care and should not be left alone. She said the IDT talked about how the family was aware of the resident's needs and how they agreed they would provide the care. She reported that the resident was incontinent, needed total care with personal hygiene, could only take a few steps, needed a wheelchair for mobility, would not be able to prepare food for himself, and needed supervision or cueing with meals. An interview was conducted with the Home Health Agency Resident #3 was referred to on 11/01/2023 at 11:50 a.m. The Home Health Agency referral staff reported Resident #3 was marked as no admit in her system. She reported the referral did not include a physician's signature, which they must have to provide the care. She said the referral was faxed back to the facility, and they called the facility but had to leave a voice mail with instructions, to sign the referral and fax it back. She said they never received the signed referral back, so they were not able to provide any home care for Resident #3. 3) Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services after a hospitalization related to dizziness and deconditioning. Diagnoses listed on the face sheet included morbid obesity, diabetes, needs assistance with personal care, high blood pressure, muscle weakness, acute respiratory failure with hypoxia (the body is deprived of adequate oxygen supply), edema (swelling), Obstructive Sleep Apnea (OSA), pain, depression, and anxiety. A review of the admission MDS Assessment, dated 09/06/2023, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A review of the resident's care plan revealed the following: Problem: Resident has impaired health status related to severe morbid obesity, acute respiratory failure with hypoxia, diabetes, and sleep apnea. (Start Date: 09/19/2023) Goal: To achieve stable health status through next review. (Long Term Goal Target Date: 12/19/2023) Approach: Continuous Positive Airway Pressure mask at night. (Start Date: 10/03/2023) Oxygen at 2 liters via nasal cannula continuous as tolerated. Promote head of bed to be elevated to facilitate stable respiratory status. (Start Date: 09/19/2023) Problem: Resident intends to discharge to home, ensure that discharge needs and goals are met (Start Date: 09/12/2023) Goal: Resident's discharge goals and preferences will be identified and met with staff assistance through the review date. (Long Term Goal Target Date: 12/12/2023) Approach: Define roles and expectations with the resident and caregiver as needed. Ensure that both the caregiver (if there is one) and the resident understand the discharge instructions and identify tasks that they will need additional help with, training for and provide contact information of a person who can serve as a resource and can answer questions that may develop. (Start Date: 09/12/2023) Encourage resident/resident representative participation and selection of provider of home health care if/as ordered. Assist with consultation\ interview if necessary and offer home health care providers contact information. (Start date: 09/12/2023). Provide the post discharge plan of care to include written discharge instructions, i.e. current health status, list of medications, follow up appointments, community resources, etc. (Start Date: 09/12/2023) Review of the physician orders, dated 09/19/2023 to 10/28/2023, revealed: Continuous oxygen at 4 liters (L) by nasal canula (NC). Review of Resident #1's progress notes revealed the following: -On 09/26/2023 at 4:32 p.m., Resident #1 requires continuous oxygen at 2 liters (L) by nasal canula (NC). -On 10/25/2023 at 10:45 a.m., SSD visited resident at bedside. Resident stated her last covered day will be 10/27/2023 that she is planning to discharge home on [DATE] with Durable Medical Equipment (DME) hospital bed bariatric. She has a bariatric wheelchair at home. Resident has her apartment key in her possession. -On 10/26/2023 at 7:35 a.m., Resident is morbidly obese. And constant complaints of shortness of breath when lying flat. Patient is using supplemental oxygen at all times. Physical Therapy recommended bariatric bed for comfort., Ease of breathing. Patient also needs bed rails to assist with repositioning in bed. -On 10/26/2023 facility staff gave Resident #1 instructions to call an ambulance transport company and arrange transportation to the resident's home. Resident #1 was not aware bariatric transport services should be requested. -On 10/27/2023 at 11:14 a.m., Resident #1 requires the head of bed (HOB) elevated 30 degrees, due to difficulty breathing when bed is lowered to provide care. -On 10/28/2023 at 8:25 a.m., Resident #1 will be discharged from the facility and transported on a stretcher by EMS (Emergency Medical Services) at 12 p.m. today. Family and resident have been informed. -On 10/28/2023 at approximately 2:00 p.m., the EMS transport service notified the facility Resident #1 could not be transported home because oxygen and oxygen equipment was not available in the home. -On 10/31/2023 at 1:57 p.m., Resident #1's oxygen (O2) was removed for 5 minutes to evaluate how the resident would tolerate room air saturation (percentage of oxygen in the blood). O2 Sat decreased to 89%. The normal O2 Sat range is 95%-100%. Interview was conducted with the SSD on 10/31/2023 at 3:18 p.m. The SSD said prior to discharge, Resident #1 told the facility staff a hospital bed and mechanical lift were the only items needed for a safe discharge as the Resident stated she had everything else. Interview was conducted with the NHA on 10/31/2023 at 3:29 p.m. The NHA said Resident #1 was her own person, but agreed the facility should have confirmed with the family whether oxygen and oxygen equipment was available at her new residence. A review of Resident #1's Transfer of Care/Discharge summary, dated [DATE], revealed the name of the medical equipment supplier without a corresponding phone number for the resident to contact the vendor if needed. A review of the Therapy Discharge Summary for Physical Therapy services provided from 8/31/2023 - 9/22/2023 signed by the Physical Therapist on 10/11/2023 showed the resident was unable to make significant functional gain due to medical complications including GI (gastro-intestinal) issues, diarrhea, and obesity. The discharge instructions read: 24 hour care, dependent assist with all ADLs. Discharge recommended location was same skilled nursing facility. A review of the Therapy Discharge Summary for Occupational Therapy services provided from 8/31/2023 - 9/24/2023 and signed by the Occupational Therapist on 09/27/2023 showed the patient's progress in therapy was hindered by medical issues, morbid obesity, decreased strength and endurance. The discharge recommendation was to continue therapy. Interview was conducted on 11/01/2023 at 10:15 a.m. with Resident #1. The resident was observed lying in bed with a nasal cannula delivering oxygen. When asked about the resident's discharge on [DATE], she stated facility staff did not ask her if she had oxygen at home prior to disch

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to advocate and provide medically related social services to ensure three (#8, #3, and #1) of five residents sampled for discharge had the community supports, services, and equipment to ensure a safe discharge to a safe and habitable location. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for the continuation of life-saving dialysis treatment, home health services, or community support to ensure food availability and food preparation for special dietary needs. Resident #3, who suffered from severe cognitive impairment, was placed in a taxi cab by himself and sent home to live with family who was not present or prepared to care for the resident. Resident #3 had an invalid order for home health services and no way to access the home upon his arrival. The taxi cab driver contacted law enforcement and Resident #3 was transported to a higher level of care. Resident #1, who was dependent on oxygen, was discharged home without medical equipment to maintain her respiratory status. The facility's system failure to ensure social services advocated and arranged for home health services, dialysis services, medical equipment, and community support services/resources resulted in the need for law enforcement intervention for Resident #8 and #3 and Emergency Medical Services intervention for Resident #1. The facility's failure created situations likely to result in serious injury, harm and/or death to Resident #8, Resident #3, and Resident #1 and resulted in the determination of Immediate Jeopardy on 09/23/2023. The findings of Immediate Jeopardy were determined to be removed on 11/02/2023 and the severity and scope was reduced to an E after verification of removal of immediacy of harm. Findings included: Cross Reference F660 1) A review of the job description for the Resident Services Director (RSD), which was the official job title of the Social Services Director at the facility according to the Nursing Home Administrator on 11/02/2023 at approximately 11:00 a.m. revealed: Summary: Has administrative authority and accountability for the provision of psychosocial needs of the residents and patients. Acts as a resident advocate, provides an ongoing program. Of activities designed to meet. The interest and physical, mental, and psychosocial well-being of each patient. Essential Duties and Responsibilities include: -Completes assessments, MDS (Minimum Data Set) assessments, care plans to collect and assess data relevant to patients' psychosocial needs, risk factors for psychosocial deterioration and responses to interventions. -Records progress notes in the clinical record including subjective findings, objective symptoms, observations of behavior, interventions provided to patient and patient's response to activity interventions. Reviews staff's chart entries for completeness and accuracy. -Delivers ABN (Advance Beneficiary Notice)/NOMNC (Notice of Medicare Non-Coverage) notices and reviews with resident/responsible party for signature. -Participates in care plan meetings and assists residents in participating as well. -Implements social service interventions that achieve treatment goals, address resident needs, link social supports, physical care and physical environment to enhance quality of life. -Coordinates discharge planning. -Facilitates advance directive decision-making process. -Completes required forms and documents in advance with company policy and state and/or federal regulations. Other Requirements: -Monitors and ensures compliance with company policies, procedures, and state and federal law. Review of the undated facility policy titled Transfer or Discharge, Preparing a Resident for revealed: Policy Statement: Residents will be prepared in advance for discharge. Policy Interpretation and Implementation: A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and /or his or her family, at least twenty four (24) hours before the resident's discharge or transfer from the facility. Review of the undated facility policy titled Discharge Summary and Plan revealed: Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy Interpretation and Implementation: -When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.) a discharge summary and a post - discharge plan will be developed which will assist the resident to adjust to his or her new living environment. -The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: -Special treatments or procedures (treatments and procedures that are not part of basic services provided); -Medication therapy (all prescription and over the counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident.) -Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. -The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: - Where the individual plans to reside; - Arrangements that have been made for follow up care and services; - What factors may make the resident vulnerable to preventable readmission; and - How those factors will be addressed. -The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. -The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. -Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. -If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 2) Resident #8 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease (ESRD) requiring dialysis, temporary catheter in upper right chest for dialysis, diabetes, altered mental status, adult failure to thrive, unspecified sequelae of cerebral infarction, chronic pain, abnormalities of gait and mobility, and muscle weakness. A review of the MDS (Minimum Data Set) admission assessment dated [DATE] revealed the resident was able to make himself understood and he was able to understand others. The resident's BIMS (Brief Interview for Mental Status) score was 11, indicating moderately impaired cognition. In Section G: Functional Abilities, the resident was assessed as requiring extensive assistance with one staff for toileting, personal hygiene, and dressing; supervision with one staff for walking in his room or for short distances, with his balance described as unsteady. The resident was occasionally incontinent of urine and frequently incontinent of bowel. A review of the resident's care plan, dated 09/26/2023, revealed the following: Problem: discharge: Resident's discharge plan is uncertain at this time as he lost his home in the community. (Start date 09/26/2023) Goal: Resident will receive assistance with discharge planning should preferences change through the review date. (Long term goal target date: 12/26/2023) Approaches included: Ask about returning to the community with each assessment; Re-evaluate preferences regarding discharge planning regularly and PRN (as necessary). (Start date: 09/26/2023) Problem: Nutritional Status: Resident is at nutritional risk r/t (related to ): ESRD, new dialysis, hx (history) CVA (Cerebral Vascular Accident). (Start date: 09/27/2023) Goal: Resident's weight will remain less than +/- 5% weight change within a 30 day time period through next review. (Long term goal target date: 12/27/2023) Approaches included: Resident will attend dialysis as scheduled Tuesday, Thursday, Saturday; Resident will receive a no added salt diet, avoid potatoes, tomatoes, bananas, oranges related to high K (potassium) content. Problem: Cognitive Loss/Dementia: Resident has impaired cognitive skills as evidenced by deficits in short and long term memory (Start Date: 10/02/2023) Long Term Goal: Resident will continue to stay safe in his/her environment. (Target Date: 01/02/2024) Approaches included: Provide cue and prompting if resident is unable to complete a task independently; Staff will anticipate and meet resident's needs. (Start Date: 10/02/2023) A review of the Therapy Discharge Summary for Physical Therapy services provided from 9/20/2023 - 10/05/2023 for Resident #8 revealed the patient was unable to make significant functional gains due to being dialysis dependent and fatigued post dialysis. The discharge instructions included the resident's need for assistance with all Activities of Daily Living (ADLs). A review of the Transition of Care/Discharge Summary revealed Resident #8 would be going back to his home address on 10/06/2023. The document showed the resident was responsible for himself with no resident representatives or community support/resources listed. Special instructions on the form recommended for the resident to continue to avoid foods high in potassium and eat 6 small meals a day to aid in controlling blood sugars. A phone number for the Certified Dietary Manager was included to help the resident with food items but no directions were included to indicate how the resident would obtain or prepare food. The form included no information in the area of special treatments and procedures or medical equipment. The form was obsolete of: arrangements for transportation to Dialysis Center, the name, address, and phone number for the Dialysis Center, the scheduled days for Dialysis treatment, any continued arrangements to receive nursing or therapy services to include the name and contact information for a home health agency. Review of the Social Services Director (SSD) progress note dated 10/05/2023 revealed a referral had been made to a Home Health Agency. A telephone interview was conducted with the Home Health Agency on 10/19/2023 at 11:08 a.m. The Referral Intake Associate reported they did not have Resident #8 in their system to provide home health services following his discharge on [DATE]. The Referral Intake Associate confirmed they made no visits to Resident #8 after he was discharged from the facility on 10/06/2023 and no Physical Therapy, Occupational Therapy, or Registered Nursing services had been rendered. A review of Resident #8's progress notes revealed: -admission note, dated 09/19/2023: The resident was alert, verbalizing appropriately, tearful at times and stated he was unsure of dialysis. -Social Services Director (SSD) note, dated 09/20/2023: The resident appeared alert and oriented x 3, with a plan of discharge to remain in the facility long term care for now. -An IDT (Interdisciplinary team) note, on 09/26/2023, documented a continued need for a skilled level of care and continued work with therapy. The note indicated the discharge plan was uncertain at this time as he lost his home in the community. -10/02/2023 a note by the SSD indicated the plan for discharge was to go out of state to Indiana. -10/04/2023 the resident was presented with a Notice of Medicare Non-Coverage (NOMNC) showing the LCD (last covered day) of Medicare coverage to the facility was 10/05/23 and the resident chose not to appeal this decision. - SSD note, dated 10/05/2023: The resident would be going home to the address noted on his face sheet from admission and a name and address for the Home Health Agency was listed. -10/06/2023 a nurse's note confirmed the resident had been discharged to home by taxi. - Progress note, dated 10/09/2023 at 1:00 p.m., revealed the Administrator received a call from the Social Worker at the Dialysis center where Resident #8 had been receiving services. The Social Worker asked the Administrator why they discharged the resident to a condemned trailer and also apprised the Administrator the resident had missed his last dialysis treatment, on 10/07/2023. The Administrator told the Dialysis Social Worker the facility was not aware the resident's home was condemned and didn't know he had skipped dialysis the day after he was discharged home. The Administrator explained to the Dialysis Social Worker, as documented in her progress note written on 10/09/2023, she had met with the resident with the facility SSD to explain to the resident he was welcome to remain at the facility during the Medicaid pending process. The Administrator documented the resident informing her and the SSD he wanted to return home and showed both of them he had his keys to his home to let himself back in. After the phone call, the Administrator and the facility SSD drove over to the resident's home and saw the home was a trailer that generally was in good repair, but had two windows broken out. The resident was sitting outside of the trailer and told the facility staff his neighbors were working on fixing up the trailer for him. After receiving permission, the SSD looked inside of Resident #8's trailer and documented garbage, filth, a horrible odor, and a piece of orange paper in the doorway. The orange paper was a condemned notice. When the facility staff told Resident #8, he could not remain living in a condemned trailer he became verbally abusive. The facility staff phoned 911 and the police officer who responded told the resident he could not remain in a condemned trailer and if he did, he was trespassing. When the officer offered the resident three choices --going to the hospital, jail, or returning with the facility staff to the facility, he chose to return to the facility. Upon returning to the facility the resident was evaluated by Psychiatric services who determined the resident was a danger to himself and he was involuntarily admitted to the hospital. An interview was conducted with the NHA (Nursing Home Administrator) and the SSD on 10/17/2023 at 5:00 p.m. The NHA reported they were not aware the trailer had been condemned and didn't know why the Home Health Agency hadn't called them to let them know the resident's trailer was condemned. The NHA said the resident told them his home was ok, he showed them his keys indicating he would be able to get into the trailer, and he could discharge to his home. The SSD reported she just hadn't revised the care plan to indicate he had a home in the community. They confirmed they had not investigated the home and the condition of the home. They confirmed they discharged the resident as he requested and had not followed up on the resident's statement that he lost his home in the community as documented in the 09/26/2023 care plan and IDT progress note. A call was placed to the Dialysis Social Worker on 11/02/2023 at 3:10 p.m. She confirmed the dialysis facility had not been notified of the resident's discharge from the nursing home to his mobile home. She stated she would have questioned that discharge as she was aware the mobile home had been condemned. She stated she knew about the trailer from his initial hospitalization paperwork, which led to his transfer into the nursing home. She reported the resident had been receiving dialysis at her facility for a year or two and agreed the address and schedule should have been on his discharge paperwork for him due to his fluctuating cognition. Resident #8 was re-admitted to the facility on [DATE] from the hospital. On 11/02/2023 at 9:00 a.m. an interview was conducted with Resident #8. He stated he was found at his mobile home by the lady in charge (NHA), was taken back to the hospital (for an involuntary admission), and then came here (back to the facility). He confirmed he received dialysis services and touched the dressing on his catheter located in his upper right chest, then held up his right arm to expose his new permanent vascular access for dialysis. When asked if he went to dialysis when he was discharged home on [DATE], he stated he hadn't been told the address or the schedule for his dialysis treatments when he was sent home so he had not gone. 2) Resident #3 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization with diagnoses to include senile degeneration of brain, altered mental status, vascular dementia, severe with agitation, schizophrenia, and major depressive disorder. A review of the 08/01/2023 admission Minimum Data Set (MDS) Assessment, Section C: Cognitive Abilities, showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident's mental status was described as inattentive with disorganized thinking. In Section G: Functional Abilities, the resident was assessed as needing extensive assistance with two staff for bed mobility, transferring, and toileting; extensive assistance with one staff for locomotion around the facility in a wheelchair, dressing, eating, and personal hygiene; and his gait was not steady. The resident was always incontinent of bowel and bladder. A review of the care plan, dated 08/18/2023, revealed the following: Problem: discharge: Resident has chosen to discharge home with family. Plan to return to community or other care setting at this time. (Start Date: 08/18/2023) Goal: Resident will receive assistance with discharge planning should his preferences change through the review date. (Long Term Goal Target Date: 11/14/2023) Approaches included: Resident preferences regarding his discharge planning regularly and PRN (as necessary). (Start Date: 08/18/2023) Problem: Cognitive Loss/Dementia: Resident has impaired cognitive skills as evidenced by deficits in short and long term memory with diagnosis of senile degeneration of brain, altered mental status, vascular dementia with severe agitation. (Start Date: 08/09/2023) Goal: Resident will continue to stay safe in environment. (Goal Target Date: 11/09/2023) Approaches: Staff will encourage resident to participate in cognitive stimulating activities and administer medications/monitoring for effectiveness. (Reviewed/Revised: 08/19/2023) Problem: ADL's Functional Status/Rehabilitation Potential: Resident is not independent with upper and lower body dressing. (Start date.: 08/14/2023) Approach: Provide assistance with dressing. Resident needs extensive assistance of 1 to two staff members for bathing, grooming, oral care, bed mobility, and transfers. Up in wheelchair or Geriatric chair per preference for out of bed activities. (Reviewed/Revised: 08/19/2023) Problem: Falls: Resident at risk for falling related to unsteady gait. (Start date: 08/09/2023) Approaches: Wheelchair with anti-tippers for mobility; Give resident verbal reminders not to ambulate/transfer without assistance; Place call light in reach at all times. (Reviewed/Revised: 09/19/2023) Problem: Behavioral symptoms: Resident slides self out of wheelchair onto floor. (Start Date: 09/19/2023) Approach: Assist with repositioning as resident will allow, and encourage resident to stay in well supervised area. (Start Date: 09/19/2023) Problem: Delirium: Resident presents some confusion at times. Requires reorientation, appears forgetful. (Start date: 08/18/2023) Approach: Staff will give simple directions. Allow sufficient time for resident to respond, communicate, and make decisions. (Start date: 08/18/2023) Problem: Communication: has difficulty understanding others related to cognitive loss and dementia. (Start date: 08/18/2023) Approach: Allow time for information to process when speaking to resident. (Start date: 08/18/2023) A review of the Therapy Discharge Summary for Physical and Occupational Therapy services provided from 7/26/2023 - 9/22/2023 showed: The Physical Therapist documented the resident's inability to make significant functional gain which was limited by poor cognition and the inability to learn new information. The resident was able to transfer and ambulate with minimal assistance. The Discharge recommendations from the Physical Therapist was for 24 hour home care with caregiver assistance and support of family and home health services. The Occupational Therapist documented the resident's progress was hindered by cognitive deficits. The recommendation stated the family should assist with personal and domestic tasks and home health services. A review of progress notes for Resident #3 revealed the following: -Nurses admission note, dated 07/27/2023, revealed the resident required total assistance for his Activities of Daily Living (ADL), but he was able to feed himself after staff set up the meal and provided cueing during the meal. The resident was described as alert and oriented to himself and able to answer simple yes and no questions. -On 07/28/2023 at 1:52 p.m., the SSD documented she attempted to contact the resident's next of kin several times but got no answer, so she left a voice mail. -Nurses notes from 07/28/2023 through to 08/08/2023 continued to document the resident as alert and oriented x 2, able to understand and follow simple commands, without any signs or symptoms of distress. -A note labeled IDT (Interdisciplinary Team) documented on 07/31/2023 staff had tried to contact the family but was unable to make contact and left a message. -On 08/08/2023 at 1:23 p.m., an IDT note documented the resident under skilled level of care, receiving physical and occupation therapy, making minimal progress as his cognition was a barrier to progress. There was to be a new review date by the insurance company on 08/15/2023 and the D/C (discharge) plan was to d/c home with a family member. -On 08/11/2023 the IDT note documented an attempt to contact the resident's family member to provide an update on the resident but was unable to contact the family and a message was left. -On 08/13/2023 a nurse's note revealed the resident was alert with noted confusion, not able to make his needs known to staff but understood simple commands. -On 08/15/2023 the IDT weekly review described the resident as making slow progress toward therapy goals, he remained a fall risk as he frequently attempted to get up from the wheelchair unassisted and was difficult to redirect due to impaired cognition. He remained at moderate nutritional risk and was followed by the RD (Registered Dietitian). He remained appropriate for skilled level of care. -On 08/21/2023 a nurse documented the resident as alert and oriented x 3, with periods of confusion, but able to make his needs known. He required the assistance of one staff member with ADLs, stand by assistance for transfers, and he was incontinent of bowel and bladder. -On 08/22/2023 the IDT documented the resident continued to require a skilled level of care and was receiving therapy. An insurance update had been sent with the outcome pending. His discharge plan remained to discharge home with family. -On 08/29/2023 the facility attempted to contact the family and left a voice mail with an update on the resident. -On 09/05/2023 an IDT note revealed the resident continued at a skilled level of care and was working with therapy. The note showed he was making progress toward his goals. His cognition remained a barrier to his safe discharge. His discharge plan was home with family when all of his goals were met. -On 09/12/2023, at the weekly IDT meeting, the note revealed the resident continued to require a skilled level of care with therapy. His impaired cognition remained a barrier to a higher level of safety. His discharge plan was to go home with family. A new review date for his insurance was 09/15/2023 with the insurance company asking the facility to prepare the resident and family for discharge. -On 09/12/2023 the SSD (Social Services Director) contacted the resident's family to inform them the resident would be discharged after 09/15/2023. She received no answer and left a voice mail. -On 09/14/2023 the SSD documented a note showing it was her third attempt to contact the resident's family about an insurance review and documented her desire to discuss a safe discharge with them. There was no answer, and she left a message, but received no response. -On 09/18/2023 the IDT documented the resident propelling up and down the hallways with attempts to transfer himself without assistance. The note documented the resident was not strong enough to do so and would remain at risk for falls. He continued to work with therapy services to increase his strength. -Later that day, on 09/18/2023, the nurse documented the patient remained severely confused to time and environment. He was not able to make his needs known. He was cooperative with taking medication. He continued to throw himself on the floor numerous times throughout the shift and was seen scooting across the floor several times during the shift. The physician had been made aware of the behaviors and Ativan (as needed) was given but not effective. -On 09/20/2023 the SSD documented the resident's Power of Attorney (POA) had been informed of the resident's NOMNC letter, but he refused to sign the letter. -On 09/20/2023 the SSD documented her visit, with the Maintenance Director to the resident's home to inform the family the resident's last covered day would be 09/22/2023 with a discharge home on [DATE]. Her note revealed several unsuccessful attempts at contacting the family by phone, therefore she felt an in-person visit was necessary. She documented the family had refused to sign the NOMNC letter so the resident would be discharged . -On 09/23/2023 at 8:20 a.m., the SSD documented the family had been informed of the resident's discharge and transported home by a cab service. A review of the Transition of Care/Discharge Summary report revealed the resident was not identified as being responsible for himself and was being discharged back to his home address on 09/23/2023. Under the heading of Special Instructions, therapy had documented: Pt (patient) has been receiving skilled PT/OT since admission at this facility. Pt reached max (maximum) potential and is unsafe to ambulate by himself. Pt is WC (wheelchair) bound and is independent with WC mobility within the facility. Pt recommended continued use of WC upon DC (discharge) for safe mobility. The Home Health Agency was to provide the wheelchair. A name and phone number for a home health agency was included on the form. The form was signed by the resident who was not responsible for himself and had cognitive deficits documented throughout his stay at the facility. An interview on 11/01/2023 at 11:50 a.m. was conducted with the referral staff for the home health agency listed on Resident #3's discharge paperwork dated 09/23/2023. The referral staff reported Resident #3 was marked as no admit in her system. She reported the referral did not include a physician's signature, which they must have to provide the care. She said the referral was faxed back to the facility, and they called the facility but had to leave a voice mail with instructions, to sign the referral and fax it back. She said they never received the signed referral back, so they were not able to provide any home care for Resident #3. A review of hospital records dated 09/23/23 at 1:31 p.m. described the resident as having a history of dementia and presenting to the emergency room due to homelessness. The resident's history was obtained from the paramedics as the resident presented with dementia. The note included the resident's recent stay at the facility where his insurance ran out. The facility, according to the hospital note, had tried to get in touch with the family but were unsuccessful and ultimately put the resident into a cab. The cab took the resident to an address listed on the resident's contact sheet. The note described the cab driver's reluctance to leave the resident at a home that did not appear to be lived in. Attempts by the hospital to contact the family were unsuccessful as well. Resident #3 remained at the hospital for a few days prior to being discharged to another long-term care facility. A review of a local law enforcement report, dated 09/23/2023, revealed the cab driver who took Resident #3 to his home from the facility notified the police of the resident's inability to enter his home. The police officer notified the facility the resident was sitting outside of his home without the ability to enter the home. The police officer had the resident taken to the local hospital where he was admitted . In an interview with the Administrator and the SSD, on 10/17/2023 beginning at 3:30 p.m., the SSD stated due to the family member not responding to phone calls, she went to the home with the facility's Maintenance Director on 09/20/2023 to discuss the NOMNC document and the resident's potential discharge. She reported the family member answered the door and after the SSD explained the NOMNC and applying for Medicaid so Resident #3 could remain at the facility, the family member said no. The family member would not sign the NOMNC and was not interested in applying for Medicaid. The SSD reported during the visit, the family member opened the garage door to the home to show them that work was being done inside the garage to accommodate the resident upon his return. The family member said the work wasn't done yet so he wasn't ready for the resident to return to the home. The SSD reported that because she and the Maintenance Director had spoken with the family member on 09/20/2023 about the resident's plans to return home on [DATE], and the resident would have discharge documents for the family to reference upon his return, she sent the resident home alone in a taxi cab. The SSD reported the family member said they were expecting the resident back and they would provide the care. A telephone interview with Resident #3's family member on 11/07/2023 at 10:30 a.m. revealed he called the facility on 09/22/2023 around 3:00 p.m. and spoke with an unknown staff member to request for the resident to remain in the facility for another week. He said he told the staff member he would come in on Monday, 09/25/2023, to pay privately for the extra time. The family member stated they must not have received his message because they sent Resident #3 out the next day. The family member confirmed he did not sign the NOMNC because he wasn't going to appeal the decision. He was told the resident had to leave the facility or pay privately and that was what he was going to do. The family member confirmed he was not ready for the resident to return on 09/23/2023 because the construction was not completed. An interview was conducted with the Nursing Home Administrator (NHA) and the SSD on 10/17/23 at 3:30 p.m. The NHA stated the facility had not received return phone calls from the family about Resident #3's stay or his pending discharge. Neither facility staff could remember whether the family had ever visited the resident at the nursing home. The Administrator and the SSD stated looking back, this was not a safe discharge. 3) Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services after a hospitalization related to dizziness and deconditioning. Diagnoses listed on the face sheet included morbid obesity, diabetes, needs assi