**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of a resident's private home, interviews to include facility staff members and contracted therapists, law enforcement officers, an Adult Protective Investigator (API), the Psychiatric Physician Assistant (PA), a Physician, members of the community, and the Medical Director, and record reviews to include hospital and facility clinical records, the Abuse Protection and Response Policy, the Discharge Summary and Plan policy, the Social Services Director (SSD) job description and the Nursing Home Administrator (NHA) job description, the facility neglected to conduct an assessment of a discharge location and develop and implement a discharge plan to ensure the needs and safety could be met for one (Resident #2) of seven residents reviewed for transfer/discharge. The facility neglected to follow their policy and procedures and as mandatory reporters failed to report the concern of possible self neglect to Adult Protective Services (APS) which likely led to Resident #2's death. Resident #2 was discharged to her private residential home, which was deemed to be unsafe (extreme hoarding, trash, animal feces, fleas, and rats). On 02/03/2023, Resident #2 was driven home in the facility van by facility staff. Upon arrival to the home, the facility's Driver contacted facility staff via telephone to report concerns about leaving the resident. The Driver reported that the resident's yard was littered with trash and a multitude of various items which were piled to excess and blocking safe entry into the resident's home. The driver was instructed to contact Law Enforcement (LE) and leave the resident at the home. Eleven days after the facility discharged Resident #2 she was found deceased inside of the home. The facility's failure to provide Resident #2 with the necessary goods and services to attain or maintain her well-being upon discharge, and neglecting to take action to report this unsafe discharge resulted in findings of Immediate Jeopardy occurring on 02/03/2023. The immediacy was removed on 02/24/2023 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Refer to F660 Review of the facility's undated policy and procedure titled Abuse Protection and Response Policy revealed Abuse will not be tolerated by anyone, including staff. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse, holds the highest priority. The Administrator had designated the following individual as the health center's Abuse Prevention Coordinator: The name of the Social Services Director was crossed out manually with the name of the 1st Floor Unit Manager and the facility's Administrator handwritten in. Interview with the Interim Director of Nursing providing this policy and procedure on 2/24/2023 at approximately 6:00 p.m. revealed the change to the Abuse Prevention Coordinator from the SSD to the 1st floor Unit Manager and Administrator was made that day (2/24/2023). Continued review of the policy revealed the following: Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Neglect: is the failure of the facility, its employees, or service providers to provide goods and services to our resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The TRAINING section revealed the facility will train all staff, through orientation and ongoing education in abuse prevention and response. In-service training will include at a minimum: What constitutes abuse and neglect as well as the reporting system established by the facility without fear of reprisal or discrimination. The IDENTIFICATION section revealed any resident event that is reported to any staff by other staff or any other person will be considered as a possible abuse if it meets any of the following criteria: d. Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well-being . Procedure: Any and all staff observing or hearing about such events will report the event immediately to the ABUSE HOTLINE AT [PHONE NUMBER]. The event will also be reported immediately to the Social Worker (Abuse Prevention Coordinator), Director of Nursing, or Administrator. Any and all employees are empowered to initiate immediate action as appropriate to protect a resident. Events requiring the reporting of abuse to the Abuse Hotline must also be reported to the local police. Review of the facility's policy and procedure titled Discharge Summary and Plan revised December 2016 revealed a Policy Statement of: 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: 1. When the facility anticipates a resident's discharge to a private residence, 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. 4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 5. The p [NAME]-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: a. Where the individual plans to reside; b. Arrangements that have been made for follow up care and services; c. A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity, and capability to perform required care; e. How the interdisciplinary team will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. 6. The discharge plan will be reevaluated based on changes in the resident's condition or needs prior to discharge. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 8. Resident's 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. 9. 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. 10. Resident's transferring or who are discharged to a home health agency will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. 13. Social Services Coordinator or designee will oversee discharge planning. a. Communicating with Resident and caregivers for discharge planning. b. Communicating with the primary care physician for discharge, durable medical equipment, prescriptions, etc. c. Home health services, if needed. 14. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's records. a. An evaluation of the resident's discharge needs. b. The post-discharge plan; and c. The discharge summary. Review of Resident #2's clinical record revealed hospital records, which accompanied Resident #2 on admission to the facility were present. Review of the hospital documentation revealed she was admitted on [DATE] with a diagnosis of psychosis. A review of the 11/16/22 7:38 AM history of present illness/medical history revealed patient is [AGE] year old female domiciled in a home alone with no known prior histories. Arrives from another hospital after being treated for ground level fall under [NAME] Act 52 (petition initiating an ex-parte involuntary examination in which a facility may hold a patient up to seventy-two hours for the examination and evaluation) for failure to thrive. Per [NAME] Act 52 the patient is a hoarder with rats and fleas in her home. She has had a dislocated knee and was found wedged between junk items in her garage and had been there for several days. She refuses care or treatment and is in a position where she is failing to thrive. No one resides with her and has no assistance. Per the ED (Emergency Department) Note, the patient presented from home via EMS (Emergency Medical Services) after ground level fall two days ago, states was unable to get up on her own. Police presented to her home for welfare check. They found her home in extreme disarray with animal feces and trash throughout the home. She has poor social support. Current history of present illness: Patient alert and oriented times 4, thought process linear, answering questions appropriately. Patient heavily minimizes her situation and psychiatric symptoms. She reports that she came into the hospital because she fell, but minimized the situation at her home. She reports she is not able to cook, but obtains her daily chicken salad from a nearby store, which she was able to walk to. She denied loss of appetite, but then described about 16 pounds of unintended weight loss in the last year. Patient reported that most of her family were in Russia, but reports good social support here with other Russians who she helps out with their English. The social/developmental history notes living situation: reports living alone in a home, per chart- home, is not in livable condition. Unknown at this time if Department of Children and Family (DCF) Services case filed. Denies Family members in area/social support. The patient's weight in the hospital was 102 pounds. Her insight/judgment: insight fair, judgment limited/poor. Her assessment included an addendum diagnosis of major depressive disorder, single episode, severe, without psychosis. A hospital consultation note dated 11/16/2022 indicated the hospital referring physician requested a consultation for Medial Management from the physician who also served as the Medical Director for the Skilled Nursing Facility. Review of the consultation revealed the chief complaint was inability to care for self. The history of present illness was: this [AGE] year old white female with past medical history of hypertension, chronic constipation, chronic pain syndrome of the right knee with chronic degenerative changes and deformity, secondary to history of prior proximal tibia fracture, history of osteomyelitis and osteoporosis with history of Tuberculosis (TB) in the right femur. Arrived via EMS to hospital located near Resident #2's home in [NAME] county on November 12th, 2022 at 1721 hours (5:21 PM). This occurred due to a ground level fall. Per ER (Emergency Room) provider, patient fell two days prior, unable to get up, arrived due to a welfare check. Reportedly found home in disarray, animal feces trash throughout the home. She was evaluated by tele-psych. Reportedly per the [NAME] Act 52 the patient's house was in disarray with fleas and cat feces around the house. Most of her medical history was obtained from medical records secondary to poor historian. The patient reports to this provider: I am from Russia. I moved here 28 years ago. I'm here because of my knee. The physician's impression included: 1. Inability to care for self. Case management to follow. 6. Protein malnourished, BMI (Body Mass Index) 16.5. 7. Weakness and deconditioning. Physical Therapy/Occupational Therapy, fall precautions. A review of the PASRR (Pre-admission Screening Record Review) Level II form dated 11/28/22 revealed the resident had a diagnosis of Major Depressive Disorder Single Episode Severe without Psychotic Features. The patient was exhibiting serious difficulty with interpersonal functioning, concentration, and adaptation to change. The patient has had psychiatric treatment more intensive than outpatient care. The Level II documented the patient was allegedly a hoarder with rats and fleas in her home. She was reported to have dislocated her knee. And was found in her garage, where she had been for several days. She refused care or treatment and was in a position where she was failing to thrive. Based on a clinical review of the submitted documentation and information, this individual is considered to have a serious mental illness as defined for PASRR. Specifically, this individual does have a major mental disorder with associated significant symptoms. Service recommendations: Information provided for the review, nursing facility placement is considered to be appropriate, once she is psychiatrically cleared, due to the patient's need for medical care and medication management. It appears that these services cannot be effectively provided in a less restrictive environment at this time. It is recommended that every effort be made to transition the patient to a less restrictive setting such as returning home with appropriate home health services or community services, or an assisted living facility that can meet the patient's medical and psychiatric needs, once the patient has stabilized, should this be indicated by the patient's treating physician. It is recommended that the following rehabilitative services of a lesser intensity than specialized services are added to the patient's comprehensive person centered nursing care plan: psychiatric medication management and individual therapy. The patient should be encouraged to participate in socialization and enrichment activities appropriate for her level of functioning. She should also be closely monitored by nursing staff at the nursing facility to ensure her safety and the safety of others. Given her history and the possible risk of relapse, care staff should monitor for an increase in depressive symptoms and report any problems to the treatment team. Should there be a significant change in her mental status, it is recommended that an additional level 2 review be conducted. Interview on 2/22/2023 at 3:51 p.m. with the facility's Driver revealed she had worked at the facility for about a month and Resident #2 was the first resident she had taken home. The Driver reported that on 2/3/23 she went to Resident #2's room, and the 1st Floor Unit Manager was assisting the resident to pack her belongings. The Driver stated the resident was taking everything. It could be the smallest thing, but she was taking it. I wheeled the resident down to the van and loaded her up in the van without incident. We chatted a little on the drive and she told me she had children. The Driver stated that when she arrived at the home, it looked like someone was being evicted from the property. There was stuff everywhere, wheelchairs, garbage, clothes. The garage was broken with the door stuck in the middle. I don't know what all was in there but it was a lot of stuff. I thought, I hope this isn't her stuff. I said to the resident, is this your house? She said yes, and I said there's a lot of stuff out here. Do you see all of this? The resident said yes like it was normal, and she wasn't alarmed about it. She said I am going to get out, and I am going to have the people from the church come and help me get that stuff together. In my mind, I am thinking she can't stay here. I saw the next door neighbor outside and told her, I am supposed to be dropping her off. The neighbor said, it's even worse inside. I said I can't leave her here so I called the facility and spoke to the 1st Floor Unit Manager. I sent her one picture I think. It was blurry, I don't have it anymore. The 1st Floor Unit Manager didn't know what to do so she called the Social Worker I think to get some direction. I stayed in the van with the resident. I thought, I need to bring her back so I start driving down the street back to the facility, and the resident was saying I can't go back. I don't have any money. I said ok, but do you want to go back? The resident said no, I don't want to go back. I want to stay at my house. The 1st Floor Unit Manager called me back and said I needed to go back to the house and call the police. I drove back to the front of her house and called 911. I gave them the information and they said a deputy would call me. I got a phone call back from a Deputy. He described the resident to me and asked if that was why I was calling. I said, I am trying to figure out what to do. She can't get in the garage or the front door. The Deputy said, do not go inside. There are rats everywhere with a very little trail to get through the house. He said it is worse inside then outside. He said he was very familiar with Resident #2. I asked can we take her somewhere? He said no, she is able bodied and she is going to do what she wants to do. He told me, she is going to get loud and there is nothing you can do about it. I said she already is starting to get loud as resident was getting fidgety and saying, let me out. He said unfortunately you're going to have to just let her out. I got out of the van to talk to the neighbor, while the resident was in the van saying it's my house and I'm going in. I told her she wasn't going in. The neighbor said she has electric and pays her bills. I didn't see any lights on, but I could see the fan motor moving on top of the house. When the resident realized I didn't want to let her out of the van, she asked me to take her to the neighbor's house across the street. I knocked on the door but there was no answer. Shortly thereafter, the daughter came home and said her mom would be home soon. The resident wanted to get out of the van so I had to let her out. She instructed me to put her belongings in the w/c she had in front of her house. It was getting dark and cold outside, I tried to zip the resident's jacket but it wouldn't zip. I asked the resident if she was hungry because she had a big bag of food from the facility and asked her to get back in the van because it was cold. The resident told her, I'm not getting in. The Driver got back in the van to stay warm and waited for the neighbor to come home. The Driver reported she was really worried about leaving the resident so she kept calling the phone numbers for the NHA and SSD that the 1st Floor Unit Manager gave her, but nobody was answering. At one point, I did get a call back [from the NHA], but when I answered they just hung up. I tried to call many times and I'm pretty sure I left messages too. As I am waiting, I see the resident scooting in her w/c across the street. She stood up and started going through her belongings on the yard. She found a jacket in the yard, put it on, and zipped it. I tried again to get the resident to eat, but she didn't want anything. I thought, the neighbor isn't coming, the resident won't go with me, and the NHA and SSD aren't calling me back. I didn't know what to do. I was there for a very long time, and it was starting to get dark outside by now. I started to drive away and that's when I heard honking. It was the neighbor. She said hold on, I have a Power of Attorney (POA) paper and just need two witnesses and then I can help fix this mess. The neighbor said if she can get the paper signed to be POA, she can clean up the resident's house, and get her into another facility tomorrow. The Driver was cautious but went with the neighbor to another neighbor's house. The husband answered and said no, they are not going to be a witness. The neighbor went to the resident and asked her to sign and initial the paperwork so she could help her. The resident questioned the neighbor about the document. The neighbor was honest and explained it to the resident. The resident said I'm not signing that and started to head for her house, stating she was going in. I tried to explain to the resident she could not go in because the Deputy said it was full of rats. I said they can really hurt you when you're sleeping. The resident said I have a computer room I can sleep in. I'll just close the door and the rats won't get me. The neighbor said she would get the resident to sign and the resident could stay with her on her couch that night. The neighbor said the whole neighborhood tries to take care of the resident. I asked if the resident had a phone to call her kids. The neighbor said she doesn't have kids, and she doesn't have a phone. The neighbor informed the Driver the resident's husband and mom that lived with her had died and that's when things started to get really bad and they've just gotten worse. When the Driver heard the resident didn't have kids like she told me she did, and she didn't have a phone I was even more concerned. I offered to leave a phone with the resident because I had an extra phone but the neighbor said she had given her a phone before, and she doesn't want it. It just gets lost in all of her stuff. The resident was going towards her house and standing up and I didn't know what to do. The neighbor said she would have the resident stay with her and nobody from the facility was calling me back so I left. The Driver estimated that she spent about 3 hours at the resident's home before she finally left. The Driver stated she never got a call back from the NHA or SSD, and when she got back to the facility that night (it was a Friday) everyone was gone. The following Monday, the 1st Floor Unit Manager apologized for what happened. The Driver told the 1st Floor Unit Manager, there has to be a better way for when a resident goes home. The 1st Floor Unit Manager said sorry again and really didn't know what the Driver would have to do because that was not her role. The Driver said she didn't speak to anyone at the facility about it again until around 2/18/23 when the RNC asked her about it for a statement. A follow up interview was conducted with the Driver on 2/23/23 at 8:40 a.m. to see if Deputy mentioned an open case with Department of Children and Families (DCF) or anything similar. The Driver stated, he didn't mention anything about DCF, no. Interview on 2/23/23 at 1:14 PM with the facility's SSD revealed her normal procedure for new admissions is to meet with the resident right away. She reported that she usually skims through the medical record before meeting the resident for some history but could not recall anything that stood out in Resident #2's record. The SSD stated when I initially met with the resident she told me a lot about herself. She told me she was from Russia and came to the United States (U.S.) for a better life. She was a teacher and was fluent in several languages. The resident reported that Russia was a really bad place so she came here to the U.S. and found out it was bad here too, The resident did not elaborate about what was bad in either place. The SSD stated that when she asked the resident the first question regarding past trauma as part of her assessment, the resident said to her, no honey and changed the subject. The SSD stated she did not attempt to ask the resident any additional questions related to past traumas and did not re-approach her at another time for any information. The SSD recalled from her initial visit, the resident was adamant she going to go home. The SSD stated she tried to discuss ALF's with her, but the resident told her she had been in places like that before and just wanted to go home. The SSD was informed of the information that accompanied the resident to the facility from the admitting hospital relating to unsafe home conditions. The SSD stated she did not know anything about this and never came to know of her home conditions prior to her discharge on [DATE]. The SSD recalled having a care plan meeting with the resident prior to her discharge with the 1st Floor Unit Manager, the Rehab Director, the treating therapists, the Minimum Data Set (MDS) coordinator, and the NHA. The SSD reported that nobody said anything about her previous living conditions during the care plan meeting where they discussed discharge planning. She knew the resident lived alone and reported she would have definitely done a wellness check if I had known [referring to the resident's unsafe living conditions]. When asked who would perform a wellness check, she said DCF for one and the police can also do a wellness check. If I knew about it, I would have made arrangements for that before the resident went home. The SSD stated she was not aware of the resident having any behaviors while she was in the facility. She stated the resident knew what she wanted, and what she didn't want. After this discharge, I was made aware that sometimes she would refuse medications. I was not made aware of any hoarding behaviors when she was here, but she knew that housekeeping would go in her room frequently. The SSD reported the resident had no visitors to her knowledge, but she told me that the Russian church helped her with anything she needed. The resident reported to the SSD that she had been living at wheelchair (w/c) level before she came to the facility, and she would go shopping in her w/c and described how she did this. The SSD recalled that on 02/03/2023 she received a call from the NHA and maybe the facility's Driver, but she was unsure who the 2nd person on the telephone line was. She stated it was mostly the NHA talking. The Driver was at the resident's home and there were garbage bags outside of the resident's home and up to the walkway of the home. The Driver was concerned and wanted to know what should be done. She stated she was not sent any pictures of the resident's home, but she told the NHA and Driver they should notify the police because there was clearly a situation and the resident could not be left alone outside of her home. The SSD stated she did not hear anything more about that call. Nothing was mentioned about taking the resident back or leaving her there. She stated, I just made the suggestion to call the police, calling DCF did not come up. The SSD reported that she does not ask the resident about working utilities or the condition of the home. She stated I just find out where they come from, if there is family or if they live alone, if we can assist with anything but in general, it was the physician and therapy that decide if they are ready for discharge. The SSD reported that she was not aware of the facility conducting any home evaluations since she has been working in Social Services for the past 4 years. The SSD was asked what home health (HH) agency was contacted to provide the resident with services. The SSD reported the resident's insurance required the community Primary Care Physician (PCP) to write the orders for the HH to be approved. The resident told the SSD she didn't want home health and wasn't letting anyone in her home. The resident would not tell her the name of her community PCP and said she will see the doctor when she needs to. I did not inform the resident's doctor or the ordering doctor that the resident was not going to have Home Health. I am not sure if anyone else told the Doctor. I know the APRN for the Attending Physician was familiar with the resident and had no concerns with her going home. The APRN was not informed by her that HH would not be provided. Pictures of the outside of Resident #2's home taken by an Adult Protective Investigator on 2/14/23, the day she was found deceased in her home were shown to the SSD. The SSD stated had she known about the living conditions, this would have affected her discharge planning. The SSD stated Yes it would, but who am I to tell an 80 something year old woman she can't go to her home. Interview with the NHA on 2/22/2023 at 5:08 P.M revealed she had been the facility's NHA since May 17th, 2022, and became licensed as a NHA in February of 2022. The NHA remembered introducing herself to Resident #2 when she arrived (on 12/26/22). The resident was Russian and the NHA was also Russian. The NHA was asked if she recalled any behaviors or concerns about the resident during her stay. The NHA recalled one time there was a smell coming from her room and housekeeping found a plate of food under her bed. There was also some reports that she would take things like wheelchair (w/c) cushions from another resident that didn't belong to her, but we could get it back. She didn't recall any major reports related to Resident #2 and was aware that she was discharging on 2/3/23. She confirmed that she had been asked to participate in the resident's care plan meeting a couple of days before the discharge because therapy didn't think it was safe for her to discharge home. The NHA stated she went to try and translate in Russian what therapy was telling her in case there was a language barrier, but the resident was very adamant that she wanted to go home. The NHA felt that the Therapy Director did not think it was safe because she had improved but maybe she could get even better. The NHA did not know if the resident was going home because insurance was no longer going to pay or if it was because she always wanted to go home. The NHA stated we made sure she was getting home safely with her meds, her discharge papers, and a w/c which I think she already had at home. The NHA was aware that the resident wasn't going to have HH services because she was refusing to have a PCP at home. The NHA was aware of the resident's home condition from the hospital paperwork. The NHA stated I understand this, and it was her choice to go back to that place and that was how she lived. She was alert and oriented. The NHA did not know if the resident had utilities i.e. electric, water, access to a telephone or food. The NHA stated she had a BIMS of 11 (moderately impaired cognition) in her discharge MDS so it wasn't a concern of her taking care of herself. Psych had seen her and the attending physician knew the resident. The NHA stated, people collect stuff, and they don't clean, but again that is their own choice. Of course an ALF would be more appropriate but basically, she was adamant she doesn't want to go that route. The NHA recalled the phone call with the 1st Floor Unit Manager on 2/3/23 informing her the facility's Driver called saying the resident's front yard was very trashed, and the Driver didn't feel comfortable leaving her outside. I added the SSD to the call with the 1st Floor Unit Manager. The SSD said based on the front yard, we don't know what's inside so the SSD said to call 911. The Driver called 911 and the Deputy refused to come out and said the resident was alert and oriented, and it was her right to live that way. The NHA reported she never questioned Resident #2's mental ability. The NHA recalled the Driver trying to call her, but she didn't recognize the number. Following this, the 1st Floor Unit Manager called the Driver back to tell her to call Law Enforcement. The NHA did not recall receiving pictures of the front of Resident #2's house. The NHA stated the Sheriff was aware of the resident and the resident's ways. We cannot bring her back to the facility because she was adamant about going home. The first step is to go to police and they refused to come out and the resident said the church would come out and help her clean. The NHA confirmed that nobody tried to reach anyone from the church, and they didn't know what church the resident was even referring to. The NHA was asked if this was a safe, orderly, and appropriate discharge. The NHA stated, the resident was her own person and it was confirmed by our Medical Director, his APRN, and the Deputy this was how she[TRUNCAT

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of a resident's private home, hospital and facility clinical record review, policy and procedure review and interviews to include facility staff members and contracted therapists, law enforcement officers, an Adult Protective Investigator (API), the Psychiatric Physician Assistant (PA), a Physician, members of the community, and the Medical Director, it was determined the facility failed to develop and implement an effective discharge planning process for one (Resident #2) of seven residents reviewed for transfer/discharge. Resident #2 was discharged back to her private residential home, which was deemed to be unsafe (extreme hoarding, trash, animal feces, fleas, and rats). The facility did not discuss with the resident or document the risks of being discharged back to a known unsafe living environment. The facility made no attempt to assess the resident's home environment prior to the resident's discharge to ensure a safe and smooth transition. The facility did not attempt to identify State local contact agencies and/or the resident's local church support congregation to provide possible support systems and services for the resident prior to discharge. The facility did not notify Adult Protective Services to report possible abuse or neglect at the time of discharge back to an environment where the resident lived alone and had no services planned for continuity of care, monitoring, or interventions in place to address her unsafe home environment. On 02/03/2023, Resident #2 was driven home in the facility van by facility staff. Upon arrival to the home, the facility's Driver contacted facility staff via telephone to report concerns about leaving the resident. The driver reported that the resident's yard was littered with trash and a multitude of various items which were piled to excess and blocking safe entry into the resident's home. The driver was instructed to contact Law Enforcement (LE) and leave the resident at the home. Eleven days after the facility discharged Resident #2 she was found deceased inside of the home. The facility's failure to implement an effective discharge planning process resulted in findings of Immediate Jeopardy occurring on 02/03/2023. The immediacy was removed on 02/24/2023 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Refer to F600 Review of the hospital records, which accompanied Resident #2 on admission to the facility, revealed an admission date to the hospital of 11/15/22 with an admitting diagnosis of psychosis. A review of the 11/16/22 7:38 AM history of present illness/medical history revealed patient is [AGE] year old female domiciled in a home alone with no known prior histories. Arrives from another hospital after being treated for ground level fall under [NAME] Act 52 (petition initiating an ex-parte involuntary examination in which a facility may hold a patient up to seventy-two hours for the examination and evaluation)for failure to thrive. Per [NAME] Act 52 the patient is a hoarder with rats and fleas in her home. She has had a dislocated knee and was found wedged between junk items in her garage and had been there for several days. She refuses care or treatment and is in a position where she is failing to thrive. No one resides with her and has no assistance. Per the ED (Emergency Department) Note, the patient is an [AGE] year old female presenting from home via EMS (Emergency Medical Services) after fall. Reports ground level fall two days ago, states was unable to get up on her own. Police presented to her home for welfare check. They found her home in extreme disarray with animal feces and trash throughout the home. She was noted to have a deformity on her right knee, however she states this was chronic. She has poor social support. Current history of present illness: Patient seen and examined, calm, cooperative, alert and oriented times 4, thought process linear, answering questions appropriately. Patient heavily minimizes her situation and psychiatric symptoms. She reports that she came into the hospital because she fell, but minimized the situation at her home. She reports that she is not able to cook, but obtains her daily chicken salad from a nearby store on US Highway 19, which she was able to walk to. She denied loss of appetite, but then described about 16 pounds of unintended weight loss in the last year. Patient reported that most of her family were in Russia, but reports good social support here with other Russians who she helps out with their English. The social/developmental history notes living situation: reports living alone in a home, per chart- home, is not in livable condition. Unknown at this time if Department of Children and Family (DCF) Services case filed. Family members in area/social support: denies. The patient's weight in the hospital was 102 pounds. Her insight/judgment: insight fair, judgment limited/poor. Her assessment included an addendum diagnosis of major depressive disorder, single episode, severe, without psychosis. A hospital consultation note dated 11/16/2022 indicated the hospital referring physician requested a consultation for Medial Management from the physician who served as the Medical Director for the Skilled Nursing Facility. Review of the consultation revealed the chief complaint was inability to care for self. The history of present illness was: this [AGE] year old white female with past medical history of hypertension, chronic constipation, chronic pain syndrome of the right knee with chronic degenerative changes and deformity, secondary to history of prior proximal tibia fracture, history of osteomyelitis and osteoporosis with history of Tuberculosis (TB) in the right femur. Arrived via EMS to hospital located near Resident #2's home in [NAME] county on November 12, 2022 at 1721 hours (5:21 PM). This occurred due to a ground level fall. Per ER (Emergency Room) provider, patient fell two days prior, unable to get up, arrived due to a welfare check. Reportedly found home in disarray, animal feces trash throughout the home. She was evaluated by tele-psych. Per tele-psych, vague historian. Reportedly per the [NAME] Act 52 the patient's house was in disarray with fleas and cat feces around the house. Most of her medical history was obtained from medical records secondary to poor historian. The patient reports to this provider: I am from Russia. I moved here 28 years ago. I'm here because of my knee. The physician's impression included: 1. Inability to care for self. Case management to follow. 6. Protein malnourished, BMI (Body Mass Index) 16.5. 7. Weakness and deconditioning. Physical Therapy/Occupational Therapy, fall precautions. A review of the PASRR (Pre-admission Screening Record Review) Level I form signed by the hospital Licensed Mental Health Counselor (LMHC) and dated 11/23/22 revealed: The patient had a mental illness (MI) of Depressive Disorder. She was currently receiving services for MI. Findings were based on: documented history, behavioral observations, individual/legal representation/or family support, and medications. The following questions were answered with a yes: 1. Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individuals developmental stage? 2. Does the individual typically have or may have had at least one of the following characteristics on a continuing or intermittent basis? A. Interpersonal Functioning: The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, fear of strangers, avoidance of interpersonal relationships, social isolation, or has been dismissed from employment. B. Concentration, persistence and pace: the individual has serious difficulty in sustaining focused attention for long enough period to permit the completion of tasks commonly found in work settings or in work life structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks. C. Adaptation to change: The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests, agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system. 3. Is there an indication that the individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? A. Psychiatric treatment more intensive than outpatient care? A review of the PASRR Level 2 screening dated 11/28/22 revealed: The summary of medical and social history included: According to the psychiatric evaluation with history and physical of 11/16/22, the patient was admitted under a [NAME] Act for failure to thrive. The patient was allegedly a hoarder with rats and fleas in her home. She was reported to have dislocated her knee. And was found in her garage, where she had been for several days. She refused care or treatment and was in a position where she was failing to thrive. According to the psychiatric progress note of 11/23/22, the mental status examination included the following observations: She was alert; She was oriented x 4; Appearance was appropriate; Mood was mildly depressed; Her affect was congruent with thought content; Behavior was passive; Attitude was open; . She denied hallucinations; Short term memory was intact; attention and concentration were adequate; . fund of knowledge was poor; Her insight was fair; And her judgment was limited and poor. The patient was reportedly demonstrating mild improvement . The patient had no reported history of tobacco, substance, or alcohol abuse. The available record indicated that the patient has a social support network that includes friends. The record indicated that the patient's strengths include access to care . The available record also did not appear to reflect the patient's level of capability in monitoring her health and nutritional status, or self-administering and scheduling medical treatment. The patient's ability with Activities of Daily Living (ADL's) were not specifically addressed in the available record . Based on a clinical review of the submitted documentation and information, this individual is considered to have a serious mental illness as defined for PASRR . Specifically, this individual does have a major mental disorder with associated significant symptoms . Service recommendations: Information provided for the review, nursing facility placement is considered to be appropriate, once she is psychiatrically cleared, due to the patient's need for medical care and medication management. It appears that these services cannot be effectively provided in a less restrictive environment at this time. It is recommended that every effort be made to transition the patient to a less restrictive setting such as returning home with appropriate home health services or community services, or an assisted living facility that can meet the patient's medical and psychiatric needs, once the patient has stabilized, should this be indicated by the patient's treating physician. . It is recommended that the following rehabilitative services of a lesser intensity than specialized services are added to the patient's comprehensive person centered nursing care plan: psychiatric medication management and individual therapy. The patient should be encouraged to participate in socialization and enrichment activities appropriate for her level of functioning. She should also be closely monitored by nursing staff at the nursing facility to ensure her safety and the safety of others. Given her history and the possible risk of relapse, care staff should monitor for an increase in depressive symptoms and report any problems to the treatment team. Should there be a significant change in her mental status, it is recommended that an additional level 2 review be conducted A review of the facility's admission Record revealed the resident was admitted to the facility on [DATE] from the hospital. The resident was listed as her own responsible party with no emergency contacts noted. Active Diagnoses all dated 12/26/22 included: muscle wasting and atrophy (not elsewhere classified multiple sites), Essential Hypertension, Age related osteoporosis without current pathological fracture, chronic pain syndrome, and major depressive disorder (single episode unspecified). Review of the social services admission evaluation, which began the discharge planning process revealed the Social Services Director (SSD) met with the resident on 12/27/22 (one day post admission). The SSD documented the admission diagnosis as major depressive disorder, psychosis. It was noted the resident previously lived alone and had no assistance in the previous setting. She had a wheelchair and cane at home and the resident's overall discharge goal was to discharge to the community. The resident had no children and per the resident, had no family or community support to list. The resident reported no drug or alcohol abuse and refused to participate in the brief trauma questionnaire. The mental health status section of the form listed a diagnosis of depression. With the history of treatment documented as: Zoloft (an antidepressant medication). This section documented referral to psychiatry and psychology. There was an area to check if the PASRR Level II was initiated and it was unchecked. The comments section of the form stated resident is alert and oriented to person, place and time upon interview. Previously lived alone in her single level home and plans to return there when appropriate. Resident is not interested in long term care or assisted living options. Resident confirmed full code status and does not wish to place any advanced directives. Resident is her own responsible party and capable of giving informed consent to participate in her health care decision making. The form noted that the Brief Interview for Mental Status (BIMS), cognitive function, and PHQ-9 (9 question Patient Health Questionnaire used as a diagnostic tool to screen for the presence and severity of depression) was conducted by therapy staff. The social services admission evaluation contained no information relating to the resident's prior home conditions contained in the hospital records and the Level II PASRR screening, which were present in the resident's medical records. A review of a progress note dated 12/28/22 by an Advanced Practice Registered Nurse (APRN) who works with Resident #2's Attending Physician revealed the resident was seen for initial evaluation. The history of present illness (HPI) includes information relating to the recent hospitalization on a [NAME] Act 52. The note states patient was reported to be a hoarder with rats and fleas in her home and very neglected state of being. The patient is currently reporting weakness in her lower extremities with muscle strength 3/5. Patient continues to require assistance with physical and occupational therapy, around the clock supervision, ADL performance, medication administration, and transportation to medical appointments to prevent hospitalization. Will obtain basic labs in subsequent visits and monitor closely. The progress notes a social history with reports of drinking red wine, living home alone where she was found to be hoarding to extreme extent and DCF was looking into the case. Patient denies family support. A 2nd progress note was completed on 12/30/22 by a Physician working in the practice with Resident #2's Attending Physician. The reason for this appointment was documented as an initial history and physical. This note indicated that the resident was admitted to the facility after a hospitalization with inability to care for herself. It contained the APRN's 12/28/22 social history of drinking red wine, living home alone with hoarding to extreme extent, DCF involvement and no family support. The treatment plan included: Chronic pain syndrome with notes to increase physical activity, stretching and strengthening exercises; Depressive disorder with single episode in remission with notes to continue on Zoloft 50 mg one tablet orally once a day and; Essential Hypertension with notes to continue Norvasc tablet 5 mg one tablet once a day and continue Lisinopril tablet 5 mg one tablet once a day with discussion of a blood pressure goal of less than 130/80. Advised to monitor blood pressure closely for the next few weeks and call the office if readings are consistently higher than 130/80. The note made no mention of discharge plans at this time. A review of the 01/08/2023 admission Minimum Data Set (MDS) assessment revealed a BIMS of 13 (intact cognition) with no behavioral symptoms noted. The resident's height was 66 inches and weight was 129 pounds. The resident participated in the assessment. The resident had no guardian or legally authorized representative. The overall expectation was to be discharged to the community and the resident was the resource for this information. The MDS indicated that active discharge planning was already occurring for the resident to return to the community. No referrals had been made to the local contact agency. Review of the care plan related to discharge initiated on 12/27/22, revised on 12/27/22, and last reviewed on 1/31/23 revealed Resident #2 is here for short stay placement: r/t [related to] major depressive d/o [disorder]. Resident/representative clearly expresses desire to discharge from facility. Plans to discharge facility when medically cleared. The care plan goal was for resident to participate in the discharge planning process throughout stay to ensure safe discharge. This care plan included only one intervention. Assess future placement setting to determine if resident's needs will be met. The position responsible for the intervention was listed as social services (SS). The care plan contained no information related to any behaviors. A baseline care plan/summary with an effective date of 1/18/2023 revealed the following relevant information: My initial discharge plan: return to home. Thinking ability/Judgment initial goal: I will improve with my thinking/judgment abilities. Dressing, grooming, bathing initial, goal: I will improve my self-care abilities. Falls/mobility initial goals: I will make improvements with my mobility. Discharge initial goal: I. Will participate in my discharge planning process throughout my stay. Short term interventions: A. Evaluate my future discharge setting to determine if it is appropriate. B. Update me on my progress toward discharge. C. Determine my need for outside services; Contact my provider and set up my services. D. Obtain my discharge orders from my doctor when appropriate. The document was electronically signed on 01/18/2023 by the 1st Floor Unit Manager/Licensed Practical Nurse (LPN). Review of Resident #2's clinical record revealed she was seen for a psychiatric evaluation on 01/13/23 by a Psychiatric Physician Assistant (PA). The note indicated occasional use of alcohol. Discussion with the patient revealed she denied any past psychiatric admissions, however, records indicated multiple [NAME] Acts, with the most recent one ordered secondary to failure to thrive. Review of the chief complaint/nature of presenting problem/history of present illness revealed a review of the hospital records was conducted and included notes of the resident being found by EMS followed a fall which occurred 2 days prior. The police presented to her home for a welfare check and found her wedged between junk items in her garage surrounded by animal feces and trash. She did not sustain any injuries but eventually was involuntarily [NAME] Acted due to failure to thrive. While the resident persistently denied any psychiatric symptoms, she noted a 16 pound unintentional weight loss in the past year per the hospital records, but she also informed the PA of a 69 pound weight loss. Per staff interview, the patient was compliant with her psychiatric medications and plan of care. The PA conducted a PHQ-9 Evaluation with a total score of three (no action required if less than 5). The patient's short term memory was noted to be fair, long term memory was good, concentration was fair, insight was fair, and judgment was fair-impaired. Her fund of knowledge was intact and she was alert and oriented to person, place, and time. The PA diagnosis was moderate episode of recurrent major depressive disorder. The PA recommended the resident to continue taking the antidepressant medication at the same dose and discussed with nursing staff to monitor for changes in mood and behavior and contact psychiatry if patient begins to exhibit any signs of worsening depression, anxiety, sleep, appetite or psychotic symptoms. The goal was to reduce polypharmacy, keep patient at the lowest effective dose of medications, and to prevent future hospitalizations. A second visit was conducted by the Psychiatric PA on 1/27/23, just one week prior to discharge on [DATE]. The reason for the visit was: Primary Care Physician (PCP)/staff request. The information obtained during the visit was from the patient, chart review, and nursing staff. The chief complaint/nature of presenting problem was depression, paranoia. The history of present illness noted staff requested patient to be evaluated today for strange behaviors and paranoia. Staff reported patient has been urinating in containers and keeping them in her room. They also reported she has been hoarding food items in her drawers and in her closet. Staff reported she is cooperative with care and medications. She was initially cooperative during the visit, but then became more guarded and agitated when psychiatric related questions were asked. She stated, Who sent you? Are you from the Secret Service? Patient became paranoid and refused to answer any other questions regarding depression, anxiety, sleep, appetite, or psychotic symptoms. The patient reported, I am fine, I do not need psychiatry. The mental status examination revealed the resident appeared calm, cooperative, with good eye contact, and was guarded. She was alert and oriented to person, place, and time, speech was coherent. Her mood appeared euthymic. affect was paranoia, guarded, thought process was organized, hallucinations were denied, delusions was paranoid, short term memory was fair, long term memory was good, concentration was fair, insight was fair, judgment was fair-impaired. Diagnoses for this visit included moderate episode of recurrent major depressive disorder and paranoia. Recommendations were: 1) Continue on the antidepressant at the same dose, discuss with nursing staff to monitor patient for changes in mood and behavior, and contact psychiatry if patient begins to exhibit any worsening signs or psychotic symptoms; 2) Paranoia/possible delusions - patient may have more underlying psychiatric illness than depression. Staff reports her home exhibited signs of hoarding. Now she is displaying paranoia and possible delusions. Will continue to monitor and not start on any antidepressants at this time; 3) Goal-To reduce polypharmacy, keep the patient on the lowest effective dose of medications, and prevent future hospitalizations and; 4) Will follow-up in two to four weeks or as needed. The form was electronically signed by the PA on 2/2/23. A review of a Psychology Evaluation conducted 2/1/23 by the facility's consulting Licensed Clinical Social Worker (LCSW) revealed the reason for referral/chief complaint was increased depression. History of present illness revealed patient was an [AGE] year old female brought here for knee problems. She was referred for assessment due to reports of depression. Staff description of patient behavior was noncompliant with no additional details noted. The history was obtained from the patient, chart review, and nursing staff. The evaluation contained no information related to the recent hospitalization or unsafe home environment the resident had been removed from. A review of systems revealed a loss of interest but no anxiety, psychotic symptoms or other concerns were noted. The mental status exam revealed the resident was calm, cooperative, alert to person, place, and time. Her speech was coherent, mood was irritable, thought process organized, hallucinations and delusions were none, and suicidal/homicidal ideations were marked no. The resident's insight was fair, judgment was fair, short term and long term memory was fair, and concentration was fair. A PHQ-9 was conducted by the LCSW. The resident scored a 3 (nearly every day) for the following questions: Little interest or pleasure in doing things. Feeling down, depressed or hopeless. Feeling tired or having little energy. The total score was 9 (an increase of 6 points from the PHQ-9 conducted on 1/13/23 by the Psychiatric PA). The summary of the session noted the patient was brought here for knee problems. She denied any history of substance use or anxiety but did report a history of depression. She stated her depression was increased right now due to her medical condition and was unsure what makes it better or worse at this time. Patient feels like she has been harassed since being in the U.S. due to being from Russia. She is not attending any activities at this time, but states she would like to go. Patient used to use swimming as a coping skill before injury but now isolates in her room. Patient plans to return home after physical therapy where she lives by herself. Patient declined therapy and said she doesn't need it at this time. The patient's prognosis was fair and the treatment plan indicated the patient declined psychotherapy. The note was electronically signed on 02/05/2023. Review of Physical Therapy (PT) notes revealed a PT Evaluation and Plan of Treatment was conducted on 12/27/22. The Evaluation included a review of the hospital documentation to noting the resident had a fall, was unable to get up for 2 days, and was found during a welfare check. The resident's home environment was noted to be in disarray with animal feces, fleas and trash throughout the home. Complexities/Co-Morbidities impacting treatment included age, complicated medical history, concomitant cognition deficits, multiple diagnoses, multiple medications, unstable psych history, and interaction of conditions. The anticipated discharge plan was Other (patient reports she would like to return home, however, unable to care for self at the time. DC TBD [discharge to be determined]). A review of the PT Discharge Summary conducted 2/2/2023 revealed the resident did not meet the following long term goals: Safe ambulation on level surfaces to 150 feet using a Four Wheel [NAME] (FWW) with supervised assistance and 10% verbal Cues for safety. On 1/26/23, the resident was ambulating 15 feet with contact guard assistance and 75% verbal cues. On 2/2/2023 the resident refused to perform the ambulation task daily. Patient will increase dynamic standing balance supported to improve independence with functional mobility and reduce fall risks. On 2/2/23 the resident was marked poor in relation to meeting this goal with a comment of refusal to perform standing activity. Patient will propel manual w/c on various surfaces with modified independence (MI) level in order to improve independence with locomotion and increase activity tolerance for distances of greater than 300 feet. On 2/2/2023 the resident was able to propel 200 feet on even and uneven surfaces with the comment that patient was able to perform task with multiple rest breaks. The summary since the start of care noted patient was resistant to participating in skilled PT services on a daily basis. Continue to educate and patient required excessive encouragement to participate in out of bed (OOB) activity. Discharge status and recommendations: Patient discharged to live alone in private residence. (Skilled PT service recommend LTC [Long Term Care] patient refuses and stated only want to go home. Patient have been educated on therapy recommendation). Prognosis to Maintain CLOF [current level of function] = Good with strong family support. Functional Bed Mobility = MI; Transfers = MI; Level Surfaces = N/A. Stairs = DNT [did not test] Community Mobility DNT. Discharge Recommendations: Home exercise program. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 12/27/22 revealed the resident's hospital history and unsafe home environment were documented under the history/complexities. The anticipated discharge plan was Other (Unknown at this time). Review of the OT Discharge summary dated [DATE] revealed the resident did not meet the following goals: Safe performance of upper and lower body bathing with set-up assistance with use of AE (adaptive equipment) and 0% Verbal Cues for correct hand/foot placement without loss of balance (LOB) was marked as DNT (did not test) on 12/27/22, 2/1/23, and 2/2/23 with the comment patient refusing. Safe and efficiently perform lower body dressing with MI with use of AE in order to perform lower body ADL's with increased independence and safety was marked as DNT on 2/1/2023 and 2/2/23. With the comment refusing. Safely perform functional activities of choice for 1 hour in order to facilitate increased participation with functional daily activities. The resident performed 20 minutes on 1/26/23, 30-60 seconds on 2/1/23, and on 2/2/23 15 minutes. Continued review of the discharge summary revealed the patient was resistant and refused the majority of treatment and education leading up to discharge. Recommend discharge to ALF. Review of Resident #2's physician order dated 1/31/23 for discharge and signed by the Physician who visited the resident on 12/30/22 revealed: Discharge from facility to home. Follow up with Primary Care Physician (PCP) 7-10 days from discharge. May discharge with remaining medications including narcotics. Home Health Care (HHC): Skilled Nursing (SN)/Physical Therapy (PT)/Occupational Therapy (OT). Durable Medical Equipment (DME): standard manual wheelchair. No specialized services at this time. Review of all facility progress notes contained in Resident #2's medical record revealed the following notes of interest: A daily skilled note by the 1st floor Unit Manager dated 1/18/2023 showed no mood indicators observed, no behaviors observed, argumentative at times. An Interdisciplinary Team (IDT) narrative late entry note made on 1/26/23 by the MDS coordinator for 1/18/23 revealed the IDT met with resident to discuss functional status, goals, and discharge plans. Resident plans to discharge home when ready. Plan of care updated. A narrative nurses note by the 1st Floor Unit Manager dated 2/3/2023 revealed the resident was discharged home accompanied by staff transportation. Resident went with all remaining medications and personal items. A total of four Social Service progress notes were recorded during the resident's stay from 12/26/2023 - 02/03/2023. 1. 12/27/2022 2:53 PM Narrative note: resident is alert and oriented to person, place, and time upon interview. Resident previously lived alone in her single level home and plans to return there when appropriate. Resident is not interested in long term care or assisted living options. Resident confirms full code status and does not wish to place any advanced directives. Resident is her own responsible party and capable of giving informed consent to participate in her health care decision making. 2. 12/27/2022 3:08 PM Resident declined to participate in brief trauma questionnai[TRUNCATED]