**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of the facility Resident Transfer and Discharge Policy and interviews, the facility failed to provide a safe discharge to an appropriate location for Resident #49. On 05/20/25 Resident #49 was discharged to a homeless shelter with no referral for follow up care, no access to transportation and no evidence the resident's representative/emergency contact was involved in the discharge planning process or aware of the resident's discharge to the homeless shelter. In addition, there was no evidence Resident #49 was safe to discharge to this location. Upon arrival to the shelter, staff at the shelter identified Resident #49 was not appropriate to remain there and the resident voiced she wanted to return to the facility; however, the facility failed to allow the resident to return. This resulted in Immediate Jeopardy and the potential for actual harm, injury or death beginning on 07/01/25 when Resident #49's, who had diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), hypertension, depression, anxiety, and cocaine dependence whereabouts could not be determined. This affected one (Resident #49) of three residents reviewed for discharge. The facility census was 47. On 07/02/25 at 4:52 P.M., the Administrator was notified Immediate Jeopardy began on 07/01/25 when the location of Resident #49 could not be determined after the facility discharged the resident (on 05/20/25) to a homeless shelter. Information obtained during the investigation revealed concerns identified by the local ombudsman as well as homeless shelter staff related to the homeless shelter not being an adequate or appropriate and safe discharge location for Resident #49. The Immediately Jeopardy was removed on 07/03/25 when the facility implemented the following corrective actions: • On 07/02/25 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team (IDT) to discuss an incident report completed by the Administrator and Director of Nursing (DON) regarding the discharge process for Resident #49 who discharged from the facility on 05/20/25. Root cause analysis and preventative measures were discussed. The discharge policy was reviewed, and no changes were made to the policy. Those attending included the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Worker, Minimum Data Set (MDS) nurse, Medical Director, Regional Director of Clinical (RDC), Regional Director of Operations, and Admissions Employee. • On 07/02/25 six of six LPNs, four of four RNs, and one Social Service Designee (SSD)/case manager, admissions director, respiratory therapist received education on safe discharge criteria and federal regulation F627 by the Administrator and/or DON who would validate that the staff read and understood the content by verbal return demonstration. All agency nurses who had worked at the facility from 07/02/25 to 07/08/25 received the education and this would continue for agency nurses for at least two weeks. • On 07/03/25 the Administrator phoned the Youngstown Police Department and contacted the Rescue Mission to see if Resident #49 had been reported as a missing person. The facility plan included if the facility could locate Resident #49 and Resident #49 wanted to return due to being in an unsafe situation, the facility would attempt to get Resident #49 assessed for emergency PAS-RR and level of care as an immediate intervention, including transportation and re-admission if necessary and appropriate. • On 07/03/25 the [NAME] President of Operations expanded staff education related to safe discharge criteria and the regulation at F627 to all staff via the electronic education dissemination and would validate that the staff read and understood the content via return verbal demonstration. • On 07/03/25 the Administrator audited all in-house residents' medical records and care plans for any upcoming plans for discharge, to determine how many residents had plans for discharge and to ensure safe discharge would be completed. The facility identified there were no residents with upcoming discharge, as all current residents were identified as long-term care residents. • On 07/03/25 the Administrator contacted the Ombudsman and Home Choice Program to discuss present and future collaboration regarding discharge planning, in order to prevent reoccurrence. • The facility implemented a plan for the Administrator and/or DON to do monthly audits of 100% of discharges for the next three months prior to discharge to ensure they meet the requirements of F627. • The facility implemented a plan for the Administrator and/or DON to complete an audit on all new admissions to the facility to ensure all new admissions had discharge planning in their care plan per the resident's preference. Audits would be conducted five to seven times a week for four weeks, then as needed, as determined by QAPI meetings. • After three months, the facility would reduce audit frequency as determined by the QAPI committee. Although the Immediate Jeopardy was removed on 07/03/25, the deficiency remains at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #49 revealed an admission date of 02/21/25 and a discharge date of 05/20/25. Resident #49 had diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), hypertension, depression, anxiety, and cocaine dependence. Resident #49's sister was listed as her emergency contact. The resident's primary payer type on admission was noted to be Medicaid. Review of Resident #49's referral admission paperwork dated 02/03/25 revealed Resident #49 required assistance for safe medication administration, supervision and direction for activities of daily living (ADL) and medical and mental health management related to diabetes, anxiety, depression and COPD. Record review revealed Resident #49 admitted to the facility from a drug and alcohol rehabilitation center where she had been admitted on [DATE] after a hospitalization for depression. It was noted that the resident had reported being homeless in the Columbus area prior to her hospitalization. The discharge plan from the drug and alcohol rehabilitation center included the resident had come from a drug and alcohol rehab in Cleveland. The resident reported to be homeless in Columbus prior to that stay as well. The discharge plan from the drug rehab including Discharge Planning: Social work to follow patient to establish with primary care provider (PCP). Patient will need to establish with psychiatry for chronic mental health needs. Care team will need to determine the current level of support and recommend a significant comprehensive relapse prevention plan in place at time of discharge. Recommend sober living to provide safe, supportive drug and alcohol-free living environments, to provide peer accountability and support alongside regular drug testing and house meetings and Intensive Outpatient Program (IOP). Sober Living/Medication Assisted Treatment (MAT) provider. Review of the physician's orders for May 2025 revealed the resident had orders for the following medications: Topamax 50 milligrams (mg) every morning and at bedtime for mood disorder, Humalog 100 milliliters (ml) given on a sliding scale before meals and at bedtime for diabetes, Omeprazole 40 mg every morning and at bedtime for indigestion, Quetiapine 25 mg at bedtime for depression, Atorvastatin 40 mg at bedtime for cholesterol, Seroquel 100 mg at bedtime for depression, Amlodipine 10 mg by mouth once per day for hypertension, Duloxetine 60 mg one time per day for depression, Januvia 50 mg one time per day for diabetes, Alogplitin 12.5 mg one time per day for diabetes, Methocarbamol 500 mg three times per day for muscle spasms. In addition, the resident had a physician order for monitoring blood glucose levels every 24 hours for diabetes. Review of the baseline care plan dated 02/21/25 revealed Resident #49's initial discharge plan was to remain in the facility. Review of a facility document titled Care Plan Conference Summary, dated 02/24/25 and authored by Social Service Designee (SSD) #214 revealed Resident #49 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Resident #49's discharge potential was marked homeless. There were no special requests for discharge. Under the summary of discussion section, it was noted D/C (discharge) plan: wants to D/C to Columbus, Ohio, homeless. Sister lives in Columbus, won't let R stay with her. However, no comprehensive care plan was developed or implemented related to the information contained on the care plan conference summary to ensure adequate and proper discharge planning was in place for the resident. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/28/25, revealed Resident #49 had intact cognition. The assessment included Resident #49 was independent for toileting, required (staff) supervision for dressing and personal hygiene and staff set-up help for eating and oral hygiene. The MDS noted the resident's goal was to discharge to the community. Review of a Case Note Report dated 03/17/25 completed by Long Term Care Consultation (LTCC) Employee #210 revealed an in-person visit was completed at the facility to review generation of participating provider level of care (PAR LOC) with Resident #49 and LTCC Employee #210. The facility social worker was in morning meeting during the LTCC. Documentation on the report revealed Resident #49 appeared alert and oriented to person, place, and time and able to actively participate in the consultation process. Resident #49 reported diabetes, blood clot in lung, mental health diagnosis, and minor weakness. A falls risk tool completed revealed some fall risks were identified at this time, such as weakness, diabetes, and many medications taken. Discussion of in-home services available to reduce fall risks, emergency response system (ERS), as well as encouragement of continued use of durable medical equipment (DME), consultation of physician, and removal of throw rugs and other fall hazards. The assessment revealed Resident #49 required hands-on assistance with instrumental activities of daily living (IADL). (IADL included managing finances, shopping for groceries, preparing meals, housekeeping, transportation, etc.). The documentation included it was not clear if Resident #49 was realistic about all her needs. Resident #49 said she could self-medicate but currently received set-up and prompting. Currently, family and friends could not offer regular support throughout the week. She reported she had a sister in Columbus. No informal support received. She stated she was on a list for apartments from the work of a social worker but does not recall details. All criteria discussed for Medicaid, low-income housing (LIH), home energy assistance program (HEAP), Assisted Living Waiver Program (ALWP), Family Caregiver Support Program (FCSP), and community resources, including Title III and Sr. [NAME]. Information for Veterans Service Commission and services available through Veteran's Affairs (VA) were discussed and offered. Information on community resources was discussed and provided to Resident #49. A Community Service Plan was developed with Resident #49's input for community discharge assistance (Home Choice), Assisted Living (AL) Waiver/PASPORT (Direction Home, and Title III services ([NAME] County). Numbers were provided for utilization. Resident #49 was provided with contact information for all providers mentioned in the Community Plan. Information on the appeal rights process was discussed and how to request a hearing. The note indicated Resident #49 would continue to work with the social worker and call on her own, as requested. Resident #49 was aware she could request another consultation if her needs changed. Contact information, information/pamphlets discussed, and Community Service Plan was completed and provided. Record review revealed no facility comprehensive care plan was developed or implemented related to the information contained on the case note report following the review completed on 03/17/25 to address the resident's discharge planning needs and/or to ensure an adequate and proper discharge planning was in place for the resident Record review revealed a 30-day discharge notice was issued to Resident #49 dated 05/09/25. The document revealed a 30-day discharge notice was issued on this date for non-payment and due to Resident #49 significantly improving enough that she no longer needed services provided by the facility. The proposed discharge location on the 30-day notice was to a homeless shelter- the Rescue Mission of the Mahoning Valley. Review of an Administrator note dated 05/14/25 at 10:57 A.M. revealed Resident #49 received a call from the Ombudsman (#209) concerning the 30-day discharge. The Ombudsman requested the facility assist the resident with an application for Home Choice (the Home Choice program is a Medicaid initiative designed to help adults age [AGE] and over leave long-term institutional settings, like nursing homes, hospitals, or intermediate care facilities, and return to living in their own homes or community-based settings). The note included an application was sent for the Home Choice Program (reference number 202505141C6R). Further review of the medical record revealed no evidence the facility administration had followed up on Resident #49's discharge plan to go to Columbus or to help her apply to Home Choice until the Ombudsman called the facility on 05/14/25. Review of Resident #49's plan of care revealed no care plan was developed related to the resident's desire to discharge to the community or following the referral made to Home Choice. Review of the physician's orders revealed a verbal order dated 05/20/25 from Medical Director #205 to discharge Resident #49. Review of the progress note dated 05/20/25 authored by Admissions #208 revealed Resident #49 was discharged to a local homeless shelter on 05/20/25 via a private vehicle, after Admissions #208 spoke with Director of Women and Families (DWF) #203 (from the homeless shelter) and completed an intake assessment. Resident #49 was discharged with her personal belongings and remaining medications. The note included Resident #49 chose to relocate to the shelter. She did not require home health or medical equipment. Review of the Discharge summary dated [DATE] revealed Resident #49 was discharged to a local homeless shelter with her medications. There was no documented evidence that this information was shared with the Rescue Mission. There were no prescriptions sent, and no follow-up appointments scheduled. Review of the resident's medical record revealed no additional social service notes/discharge planning notes during this time period or after the Care Plan Conference Summary Note (dated 02/24/25). Interview on 07/01/25 at 9:14 AM with Resident #49's sister revealed she was not contacted by the facility to discuss the resident's discharge plan. She stated if they would have asked her if she was able to care for her sister, she would have said no because she did not have room, but they did not contact her. The resident's sister was not able to provide any additional information as to the resident's current location. Interview on 07/01/25 at 9:51 A.M. with the Administrator revealed Resident #49 along with Admissions #208 spoke to the homeless shelter and completed a phone assessment prior to discharge on [DATE]. The Administrator stated Resident #49 was told the homeless shelter could help take care of all her appointments and medications. The resident did not have a debit card and to obtain one, she would need a driver's license, which the Administrator reported the homeless shelter told her they could assist her with. Per the Administrator, at that point, Resident #49 decided she did not want to stay (in the facility) until 06/09/25, which would be 30 days after the discharge notice was issued, and she chose to leave on 5/20/25. The Administrator confirmed the facility did not attempt to place the resident at any other location because the Administrator stated the resident was anxious to leave. The Administrator also indicated Resident #49's family was contacted, and no one would allow the resident to stay with them. However, there was no documentation contained in the resident's medical record to support this. Interview on 07/01/25 at 9:57 A.M. with DWF #203 revealed Resident #49 called into the homeless shelter with a representative from the facility to complete a pre-intake assessment on 05/20/25. However, when she arrived (on 05/20/25), her abilities did not match what she and the representative told them she was able to do. The resident needed to be able to ambulate throughout the building independently as well as climb stairs to sleep in a top [NAME]. DWF #203 said Resident #49 had difficulty walking on the sidewalk on the way toward the building and needed help carrying her belongings. She also could not climb the first step on the ladder to reach the top [NAME]. The homeless shelter determined the resident was not an appropriate fit to stay, and the resident wanted to return to the facility. However, when they contacted the facility, an unidentified person (believed to be a nurse) said they could not take the resident back because they did not accept discharged residents, and Resident #49 was not allowed to return due to lack of payment. The resident was permitted to stay overnight at the shelter but then left the next day. DWF #203 revealed the current location of the resident was unknown. During the interview, DWF #203 also confirmed staff at the shelter did not make appointments for residents, did not have physicians on staff, did not provide any type of transportation and had no social services available. They were a first come, first serve emergency shelter only. Interview on 07/01/25 at 10:12 A.M. with Licensed Practical Nurse (LPN) #204 revealed she was the nurse on duty who discharged Resident #49 on 05/20/25. She said the resident appeared content at the time of discharge and was hoping to eventually get herself back to the Columbus area, where she was originally from. The LPN stated the resident was discharged with approximately two weeks' worth of medications. Interview on 07/01/25 at 11:30 A.M, with Medical Director (MD) #205 revealed she was told by the facility that Resident #49 wanted to discharge to the homeless shelter. While MD #205 stated she felt this was an odd discharge plan because nursing home residents were not typically discharged to a homeless shelter, she did not oppose the resident's plan since the resident was cognitively intact. She denied having any documentation of her knowledge of the discharge or an order to discharge Resident #49. Interview 07/01/25 at 12:58 P.M. with Admissions #208 and the Administrator revealed the homeless shelter did not require any information to be sent to them regarding the resident's care needs. The Administrator revealed she was told the homeless shelter's physician would see Resident #49 and ensure she could continue getting her medications. Interview on 07/01/25 at 3:11 P.M. with Ombudsman #209 revealed she had spoken with Resident #49 along with the Administrator after the facility issued the resident the 30-day discharge notice (exact date not recalled). She stated she had asked Resident #49 what she would like to do, and the resident stated she would like to get her own place. Resident #49 stated she did not want to go to a homeless shelter. She stated the Administrator agreed to apply for the Home Choice program at that point. At the time of the interview, Ombudsman #209 had no information on Resident #49's current whereabouts or status. Interview on 07/02/25 at 8:43 A.M. with the Administrator revealed Admissions #208 contacted homeless shelters in [NAME] County (where Resident #49 previously resided) and was told they could not assist with placement until Resident #49 resided in [NAME] County. The Administrator revealed Resident #49 received a phone call from Ombudsman #209 on 05/14/25 regarding the 30-day notice. Ombudsman #209 requested the facility assist the resident with the Home Choice application, which was completed. The Administrator revealed Resident #49 did not want to reside in [NAME] County and would not have qualified for the Home Choice program because she had no income. (However, Resident #49 has SSI in the amount of $974 per month). At the time of the interview, the Administrator thought Resident #49 was still at the homeless shelter but denied knowledge of the resident's actual whereabouts as of this date. Interview on 07/02/25 at 1:18 P.M. with Ombudsman #209 revealed Resident #49 told her she received SSI in the amount of $974 per month. She also confirmed Resident #49 told her and the Administrator, she did not want to go to a homeless shelter, she wanted a place of her own. Ombudsman #209 stated that she talked to the facility about the Home Choice program first before having to take the case to an appeal. On 07/07/25 at 8:16 A.M. interview with the Administrator revealed she was the person who drove Resident #49 to the Rescue Mission on 05/20/25. The Administrator revealed the resident was taken in a personal vehicle to the shelter. Interview on 07/07/25 at 9:23 AM with Assistant Director of Ombudsman #211 revealed the Administrator called on 07/06/26 and asked very general questions related to what was expected when they discharged a resident. The Administrator did not discuss or ask anything specific about Resident #49. Review of the email communication dated 07/08/25 of the case notes from Transition Coordinator (TC) #215 revealed the Home Choice assessment review took place 06/02/25. The assessment included Resident #49 needed some physical assistance with dressing and bathing such as set up and cues. The resident required total assistance with set up and reminders for Humalog injections. A call was made on 06/03/25 by TC #215 to the facility since the resident did not have a telephone. TC #215 was told by the facility Resident #49 was no longer at the facility and was sent to the Rescue Mission of the Mahoning Valley on 05/20/25. The case was closed on 06/04/25 due to the resident being discharged after the assessment without home choice assistance. Interview on 07/08/25 at 1:51 PM with Assistant Director of Ombudsman #211 revealed she believed Resident #49 was assessed for the Home Choice program on 05/19/25 and approved the same date. Review of facility undated policy titled Resident Transfer and Discharge Policy and Procedure revealed the facility would discharge residents in a safe manner to include the specific services the receiving facility would provide to meet the needs of the resident, documentation of the discharge by the physician, contact information for the practitioner responsible for providing care for the resident, resident representative information including contact information and all necessary information relevant to the residence discharge to ensure continuity of care. This deficiency represents noncompliance investigated under Complaint Number OH00167024.