**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)1 was free from of accident/hazards, over which the facility had control of on 04/26/25. The facility staff loaded R1, who is a bilateral amputee to his lower extremities, with a Hoyer lift to a boat, allowing him to ride on a highway without being properly secured. On 06/05/25 at 5:39 PM, the survey team provided the Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 04/26/25. The IJ was related to 42 CFR 483.25 - Quality of Care at F689- Free of Accident Hazards/Supervision/Devices. On 06/06/25 at 1:14 PM, the facility provided an acceptable IJ Removal Plan. On 06/06/25 at 2:15 PM, the survey team validated the facility's corrective actions had been implemented. The IJ was removed and lowered to a Scope/Severity level of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: A review of the facility's policy titled Safe Lifting and Movement of Residents (n.d.) stated, In order to protect the safety and well-being of staff and residents, and promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, multiple sclerosis, bipolar disorder, acute kidney failure, history of falling, acquired absence of left leg above knee, and acquired absence of right leg above knee. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/25 revealed R1 scored a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. Review of Section GG0015 of the MDS indicated impairment on both sides to lower extremity. Review of R1's Nursing-Fall Risk Observation/Assessment dated 05/23/25 indicated the following: 3. Balance: Evaluate resident's balance while standing, sitting and during transitions. This was coded as 2. Non-ambulatory/ wheelchair for locomotion. 6. Mobility was coded as non-ambulatory/wheelchair for locomotion. Confined to chair/geri-chair, coded as yes. During an interview with R1 on 06/05/2025 at 11:34 AM, R1 stated, The whole going boating thing was his and his friend's idea. This has never been done before. He stated, I did express to the staff my idea, Licensed Practical Nurse (LPN)1. LPN1 stated that we could not go on the boat without authorization and she contacted the Operation Manager (OM)1, who was the administrator at that time. This happened on Saturday, before Mother's Day, I am unsure of the date. LPN1 said that OM1 called back and said it will be alright to go fishing. The staff and I thought the best way was to unload and load me was with the crane. It was mostly LPN's idea. When I sat on the seat, we noticed that there was no seat belt. LPN1 secured me with a sheet under my arms and tied it behind me, behind the seat, so I would not move at all. I was able to move very little with the sheet there, mostly my arms. I could not move my lower chest to lower body with the sheet. I was loaded in the boat by Certified Nursing Assistants (CNA) and LPN1. I am unsure of the CNA Names, there were maybe 3, or 4. I was driven to the dock, while I was tied up on the boat. It is roughly about five miles. We got on the water and started to go to the lake to go fishing. The boat started filling with water. R1 then stated his friend stated, I think we are sinking. R1 said, I was not too concerned because I had on a life vest. Everything seemed so surreal. A passerby boat was waved down, and they pulled us back toward the dock. EMS came out and had to pull us out the water because the lake authority was called because the boat was sinking. 911 was called. One of the buses came and got me, it was a wheelchair bus. When I got back to the facility, they assessed me, I had no injury at all. I am trying to block out this memory. It was the worst experience I had since living here. Social Services did talk to me briefly. It could have been much worse. I will never go fishing or get on a boat again. During an interview with CNA1 on 06/05/25 at 12:10 PM, CNA1 revealed, We debated about doing it and we called OM1. He [OM1] said to give him a minute, and he would call back. OM1 called back and said it was okay. OM1 spoke with LPN1. LPN1 said it was okay to put him in the boat. CNA1 stated, We got the Hoyer lift and put him in the boat with the lift. All four CNAs was standing on the ground at first. I climbed on top of the boat then to ensure he did not fall. It was not part of the plan; we thought he would have a seat belt. R1 insisted on going, even without the seatbelt. The sheet was his friend's idea. I just got down off the boat. I don't know what happened with the sheet, I came back in the inside. During an interview on 06/05/25 at 12:28 PM, R1's Friend stated that he and the resident had the idea of going on a boat to fish on the lake. He stated, The nursing home thought of the sheet because R1 fell over. R1 kept sliding down, so they tied him up. They tied him down to ensure he stayed in one spot. The nursing home tied up the sheet, I did not tie up the sheet. It worked; he did not slide down anymore. During an interview on 06/05/25 at 12:34 PM, the Director of Nursing (DON) stated, OM1 called him after the fact, and he looked up the South Carolina law. He stated, It was not a law against driving a patient on a boat on the roadway, please review this section. At this time, the Surveyor was shown Section 56-5-3900 of South Carolina State house which pertains to transportation of minors in open vehicles. Review of the document titled, Code of Laws-Title 56-Chapter 5- Uniform Act Regulating Traffic on Highways; Section 56-5-3900. Transportation of minors in open vehicles stated, (A) It is unlawful to transport a person under fifteen years of age in the open bed or open cargo area of a pickup truck or trailer. An open bed or open cargo area is a bed or cargo area without permanent overhead restraining construction. Review of photographic evidence revealed R1 sitting in the back of the boat, without a covering above him. During on 06/05/25 at 12:42 PM, CNA3 stated, I was not out there really, but I helped for a while. I don't know who tied him up. During an interview on 06/05/25 at 12:55 PM, CNA2 revealed that she was not in charge of his care, but she and other staff members assisted him onto the boat by Hoyer Lift. She stated that she doesn't ' t remember how he was secured on the seat. She left and went on the inside. LPN1, CNA1, and CNA3 was out there when she left. She stated, We got the okay from the Administrator via the phone that is why we did it. On 06/05/2025 at 11:59 AM, LPN1 was called but mailbox is full. Attempted to call again at 12:20 PM. At 2:34 PM, another unsuccessful attempt was made to contact LPN1. On 06/05/2025 at 2:19 PM, attempts were made to contact OM1 via telephone, with no success. The following information constitutes [NAME] Post Acute removal plan for the immediate jeopardy. Summary of Incident: Resident 1 left the faciity on his own accord on 4-26-25 after signing out for LOA to go with a friend on his boat to fish. Staff assisted him into the boat per his request and per his request he used a sheet to hold him up on the seat. He was unable to remove the sheet himself. After he was on the boat off of the premises they incurred issues and facility was called by EMS to come and get him from the lake. He had no injuries. Timeline of Events: Resident 1 was admitted to the facility on [DATE] for LTC. He is alert with BIMS 15/15 and has decisional capacity. 4-26-25 Resident left the facility in a boat with a fried per his request to go fishing. He was placed on the boat by staff using a Hoyer lift and he used a sheet to secure him to the seat of the boat per his request. Staff received a call from EMS that the boat incurred issues and R1 was at the lake and facility needed to pick him up. Facility went to pick him up and returned him to the facility. He had no injuries. 4-28-25 Education was initiated for staff to instruct to not assist any residents into a recreational vehicle for LOA. Residents may only leave for LOA in a motor vehicle. 4-28-25 Audit was complete for month April LOA forms to ensure no other residents had left the facility in a boat. Immediate Actions Taken: 1) Resident 1 has not been out of the facility since 04-26-25 for LOA. 2) 100% Audit of all LOAs from 04-26-25 present to confirm that no other residents left the facility in a boat or unsafe vehicle for a resident to be transported in. Audit complete on 06-05-25 at 7:30 pm and no other residents have left via a vehicle that could be unsafe for their condition/situation. 3) LOA sign out sheet amended to include a column to indicate how they are leaving the facility. Type of vehicle used to leave. (see attached) 4) All staff will be re-educated to ensure understanding that a resident on LOA may not leave the facility in a vehicle that is unsafe for the condition or situation such as a boat or motorcycle and never assist with transfer to any vehicle that is not safe. Also, when a resident signs out LOA to include on the sign out sheet the type of vehicle in which they left. Medical equipment/lift shall not be used to transfer a resident for a nonmedical purpose. 5) Letter will be prepared for mailing to RR's, families and residents to inform them that to protect their safety on LOA they will only be permitted to leave the facility in a motor vehicle that is safe for the residents condition/situation. (see attached) Letters will be mailed 06-06-25. 6) Audits will be complete weekly by DON of LOA sign out sheets to ensure that no resident are leaving the facility by a vehicle that is not safe for their condition or situation. Audits will be weekly x 4 weeks then monthly x 2 months then random thereafter. Report will be submitted to QA committee to determine need for continued monitoring after 3 months. ADHOC QA Meeting Held 06-05-25 *Members Present were: RN RDCS, Dr. via phone, LSW, Director of Nursing, and RN, Operations Manager *Root Cause of issue is identified: Staff failed to ensure that a resident left the facility for LOA by a safe means of transportation. *Audit will be complete of all residents with LOA from 04-26-25 to present to ensure that no other resident has left via a vehicle that is unsafe for their condition/situation. *Education initiated for all staff by DON/RDCS to ensure understanding that any resident who signs out and leaves LOA cannot leave in any vehicle that is not safe and must leave only in a motor vehicle that is safe. Column will be added to LOA sign out sheet to indicate type of vehicle they leave in for LOA. Education will also include that medical equipment/lifts witll not be used for a transfer that is not medically necessary. Education will be complete for current staff and or agency by noon 06-06-25. New hires and agency will continue to receive education prior to first shift worked. *Letter prepared to mail to all families/RR's and residents to inform that to protect their safety during LOA they will only be permitted to leave on LOA in a safe motor vehicle and not a vehicle that is unsafe for the condition or situation. Letters will be mailed 06-06-25. *All education will be provided to newly hired staff and agency staff prior to first shift worked. The above components have been implemented as of 06-05-25 by 7:30 pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure two residents, Resident (R)83 and R6, were free from resident-to-resident physical abuse for 2 of 3 resident reviewed. Specifically, R103 was able to physically attack R83 on 03/09/25, on three separate occasions, within a forty-five-minute timeframe. Additionally, on 04/14/25, R103 spit on and hit R6. On 05/01/25 at 5:34 PM, the Operation Manager and Director of Nursing were notified that the failure to protect a resident from multiple incidents of physical abuse constituted Immediate Jeopardy (IJ) at F600. On 05/01/25 at 5:34 PM, the survey team provided the Operation Manager and Director of Nursing with a copy of the CMS IJ Template and informed the facility IJ existed as of 03/09/25. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 05/02/25 at 1:24 PM, the facility provided an acceptable removal plan. On 05/02/25 at 1:30 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification and Complaint Survey for non-compliance at F600, constituting substandard quality of care Findings include: Review of the facility's policy titled Abuse and Neglect revised March 2018 revealed, . abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse . and mental abuse . 1. Review of R103's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/07/25, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment. Review of R83's annual MDS with an ARD of 03/03/25, revealed a BIMS score of 05 out of 15 which indicated severe cognitive impairment. Review of R83's Nurse's Note, dated 03/09/25 at 9:55 AM, and located in the EMR under the ''Notes'' tab, written by Licensed Practical Nurse (LPN)3 revealed, . she heard someone yelling stop when nurse got to the nursing station she observed [R103] hitting [R83] on her right arm several times, they were separated [R103] was taken to her room and [R83] was taken to A-side. Body audit performed. During an interview on 05/01/25 at 9:48 AM, Licensed Practical Nurse (LPN)1 stated that on 03/09/25, she was in the hallway and R83 was sitting in her wheelchair in the hallway, when R103 came around the nurse's station, and went into the parlor. She heard R83 hollering, and when she ran back, she observed R103 hitting R83 on the arm and maybe on the chest with a closed fist. She immediately separated them and took R103 to her room and left R83 in hallway. A few minutes later she heard hollering again, and observed R103 had returned and was hitting R83 on her arms/chest again in the hall. At that time, she took R103 back to her room for a second time and moved R83 to the parlor by the nurse's station. Then a few minutes after that she heard hollering again and returned for a third time and found R103 hitting R83 again in the parlor. She returned R103 to her room and at that time she took R83 to the other unit. LPN1 stated R103 attacked R83 three different times in about a 45-minute period. She said she told the Certified Nursing Assistant (CNA) staff to keep an eye on R103. She said R103 understood what she was doing. Whenever someone said something to her, she did not like, she immediately began hollering and cussing. Staff have tried to keep an eye on her whenever she came out of her room. They try and watch to see where she's going. But her behaviors went from 0 to 100 in seconds. There was usually any indication when she was about to escalate. LPN1 further stated staff were not doing enough to keep her or other residents safe. She did not know what staff could do to keep them safe. If they move her to another unit, she will just do the same thing there. Review of facility documentation revealed that R83 did not have a skin assessment completed at the time the incident occurred. Review of R103's EMR Psych Consult under the Assessments tab revealed two consults were completed on 03/10/25 and 04/15/25, and medications were adjusted. The Social Service Director (SSD) sent a referral for behavioral placement evaluation on 04/15/25, but there was no follow up after that date related to the status of the referral. During interviews on 05/01/25 at 7:58 AM and 8:43 AM, both Certified Nursing Assistants (CNA) and CNA5, assigned to residents at the time the incident occurred, revealed they did not witness the incident and were unaware that R103 required increased supervision. During an interview on 05/01/25 at 3:41 PM, the Director of Nursing (DON) stated the facility substantiated the abuse. However, he was unaware that R103 was allowed to attack R83 three separate times. The DON stated it was frustrating because that was not the information that staff reported to him. Based on what he stated staff told him it was not that serious. The DON thought R103 hit R83 once and they were separated and there were no further issues. 2. Review of R6's EMR Progress Notes tab revealed a note authored by the Director of Nursing (DON) dated 04/14/25 at 3:39 PM that stated, [R6] was outside being supervised during her smoke break. The opposing resident [R103] attempted to get past the residents who were near the door but became frustrated when she could not. She then pulled one resident's wheelchair backwards causing it to strike [R6's] legs. [R6] expressed her disdain towards the opposing resident's actions to which the opposing resident said, F**k you. As staff attempted to separate the two residents, the opposing resident slapped [R6] on the knee and spit on her smoking apron. Staff continued to separate the residents immediately, and no further incident occurred. Review of facility provided incident investigation for the incident showed the initial report stated: Time of incident 04/14/25 at 3:00 PM [R103] going outside to courtyard to smoke and she pushed a wheelchair which hit resident's legs. Resident became angry and both exchanged profanities - staff attempted to intervene but before residents could be reached, [R103] smacked resident on the leg and spit toward her. Both separated immediately and taken inside. Body audit showed no injuries. During an interview on 05/01/25 at 10:20 AM, R6 was in her wheelchair wearing a smoking apron and self-propelling on the path to the courtyard. R6 remembered the incident and stated the wheelchair did not cause an injury, they exchanged some words she shouldn't have said, and R103 started spitting on her apron then came closer and closer and hitting her knee. R6 stated she went to grab her arm to stop her, but the aide pulled her away before she could do so. R6 stated her knee was a bit sore a few days. During an interview on 05/01/25 at 3:17 PM, CNA2 stated, I was watching smoking and [male resident name] asked [R103] to move him back. [R103] moved [the] wheelchair towards [R6] and [R6] say I'm back here but [R103] moved his wheelchair into her [R6] stump. I tried to get up to move [the male resident] beside [R6]. [R103] started cursing [R6] out, [R6] told her 'because of you he hit me,' they went back and forth, I told them to chill out. [R103] then spits on [R6]. Finally [DON's name] came out and took [R103] inside. He was out trying to calm [R6] down, [R103] came back out and swung around [DON] and hit [R6] on the leg. So, he took her back in and she didn't come back out. In a follow-up interview on 05/02/25 at 5:05 PM, the DON was advised of CNA2's interview. The DON denied [R103] returned to the courtyard. I brought her in and went back out to [R6], but [R103] didn't come back out. The surveyor asked how he found out about the incident, to come out, the DON replied [CNA2] reported it to me. On 05/02/25 at 1:24 PM, the facility provided an acceptable removal plan, which included the following: . Immediate Actions Taken: 1) Body audit complete for Residents 83 and Resident 6 and 103 to ensure no concerns. 2) Interview complete with Resident 83 and Resident 6 to ensure they feel safe and have no concerns with care or safety at the facility. 3) Education initiated immediately with 100% of staff by DON/DSD/RDCS/designees on 5-1-25 to ensure understanding of reporting of abuse and resident to resident altercations and ensuring that residents are kept separated and that all information and details are accurately reported to Administrative staff. 4) Interviews initiated with all residents by Admin staff and SS to ensure they have no concerns with abuse and that they feel safe at the facility. 5) Education initiated with SS, DON, Operations Manager and Admin Nursing Staff by RDCS to ensure understanding of abuse and abuse reporting and ensuring that residents are kept separated and that all behaviors and interventions are care planned timely. 6) Rooms assignments were reviewed to determine whether or not proximity was an issue for resident 103 and resident 83, and for resident 103 and resident 6, with findings revealing that resident 103 resides on a separate hall than resident 83 and resident 6, therefore no room adjustments were deemed necessary. 7) Resident 103 was placed on 1:1 observation. 8) Resident 103 care plan was updated to reflect the 1:1 intervention. 9) Psychiatric services will continue to follow resident 103. 10) Compliance completion was confirmed as of 5-2-25 at 12:45 pm. ADHOC QA Meeting Held 5-1-25 *Members Present were: [name] RN RDCS, [name] LNHA, [name] Operations Manager, [name] RN DON, [name] Dr via phone. *Root Cause of issue is identified as lack of accurately reporting events and behaviors to Admin staff and failure to ensure residents kept separated once an alteration occurred and failure to follow up and accurately care plan interventions r/t behaviors and keeping residents separated. *Education initiated for all staff by DON/RDCS to ensure understanding of abuse and abuse reporting and ensuring that residents are kept separated and free from abuse. *Interviews initiated with residents with BIMs> 12 by SS and Admin staff to ensure they feel safe and have no concerns r/t abuse. *Education initiated for all Admin Staff by RDCS to ensure understanding or reporting abuse, ensuring residents are kept safe and separated and that all interventions are care planned for residents regarding behaviors. *All education will be provided to newly hired staff and agency staff prior to first shift worked. *The above components have been implemented as of 5-1-25 by 7:30 pm, and 100% compliance was confirmed as of 5-2-25 at 12:45 pm. *The results of the interventions will be audited every shift times 4 four weeks and then every week times four weeks, and the results will be brought to the QAPI committee monthly for the duration of the interventions. *The 1:1 interventions will continue indefinitely as deemed necessary per ongoing review of 1:1 observation documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record reviews and interviews, the facility failed to ensure a resident had a safe and orderly discharge from the facility, for 1 of 1 resident. Specifically, Resident (R)1 was discharged from the facility on 04/14/23 to a motel located approximately 50 minutes from facility. Upon arrival to the motel, R1 suffered an emergent event and had to be transported to an emergency room. On 04/09/24 at 3:00 PM, the Director of Nursing and Regional Director of Clinical Services was notified that the failure to ensure a resident had a safe and orderly discharge from the facility constituted Immediate Jeopardy (IJ) at F624. On 04/09/24 at 3:04 PM, the survey team provided the Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/14/23. The IJ was related to 42 CFR 483.15 - Admission, Transfer, and Discharge On 04/16/24, during Quality Assurance (QA) of the survey, the State Agency (SA) determined that further investigation was necessary and the survey team returned to the facility on [DATE]. On 04/19/24 at 10:41 AM, the facility provided an acceptable IJ Removal Plan. On 04/19/24 at 10:41 AM, the survey team validated the facility's corrective actions and removed the IJ as of 04/09/24. Findings include: Review of the facility policy titled Discharge Summary and Plan last revised October 2022 states, Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan and The discharge plan is re-evaluated based on changes in residents' condition or needs prior to discharge. Review of the facility policy titled Discharging a Resident without a Physician's Approval last revised October 2022 states, If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, the facility will treat this situation similarly to refusal of care and will: a. discuss with the resident and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs . b. determine if a referral to Adult Protective Services or other state entity is necessary. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses included but not limited to: homelessness, bipolar disorder, anxiety, depression, chronic hypoxemic and hypercapnic respiratory failure, COPD exacerbation, acute encephalopathy, injury of head, long term use of insulin, pressure ulcer to sacral region and type 2 diabetes. Review of R1's 5 Day Entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact. Review of R1's Discharge Summary revealed R1 was discharged with a wheelchair, oxygen tank and tubing and various personal items. Review of R1's Post-Discharge Plan of Care with an effective date of 04/13/23, revealed R1 required home health services for nursing needs. The Post-Discharge Plan of Care also indicated that resident/family would provide; personal care, transportation, meals, and housekeeping. R1's Dietary and Nutritional Needs indicated R1's suggested food fluids: CCD [controlled carbohydrate diet] diet, Dysphagia Advanced texture, Thin Liquids consistency. Further review of the Post-Discharge Plan of Care revealed Amount sent with resident (regarding medications) was left blank indicating the medication was not sent with the resident upon discharge. The medications included: Pregabalin Oral Capsule 25 MG, Omeprazole 20 MG, Lucricant Eye Opththalmic Ointment, Valproic Acid Oral Capsule 250 MG, Insulin Glargine Solution 100 Unit/ML, Losartan Potassium Oral Tablet 50 MG, Fluticasone Propionate Nasal Suspension 50 MCG/ACT, Doxazosin Mesylate Oral Tablet 1 MG, Symbicort Inhalation Aerosoal 160-4.2 MCG/ACT, Amitriptyline HCL Oral tablet 50 MG, Trazodone HCL Oral Tablet 50 MG, Montelukast Sodium Oral Tablet 10 MG, Oxycodone-Acetaminophen Oral tablet 5-325 MG, Amlodipine Besylate Oral Tablet 5 MG, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT, Ziprasidone HCL Oral Capsule 80 MG, and Diazepam Oral Tablet 5 MG. The Post-Discharge Plan of Care also indicated under Wound Care, Treatments, Therapy Procedures you should do 1. Procedure/Purpose/Frequency: Santyl Ointment 250 Unit/GM (Collagenase) Apply to sacrum topically every day shift for wound care cleanse with wound cleanser apply alginate calcium after application of santyl cover with bordered gauze. Lastly, section ii which states, These discharge instructions have been reviewed with me in a language I understand. All questions have been answered to my satisfaction. I have received the medications or written prescriptions as indicated above. The signature and date sections acknowledging section ii, was left blank. Review of R1's Care Plan dated 02/22/24 revealed the following: The resident has limited physical mobility r/t weakness and recent hospitalization. The resident has an ADL self-care performance deficit r/t weakness, impairments in mobility and impairments in overall function. Resident requires assist with ADL's several times daily and prn. Resident is incontinent of bladder/bowel and is at risk for complications. Contributing factors to incontinence are: decreased ability to make self understood, decreased ability to understand others, diabetes. And Resident is at risk for Altered ADLs R/T: Decline in functional ADL activity such as: Bed Mobility (e.g., turning and positioning), Transfer (e.g. getting in or out of bed), Walking, Locomotion, Dressing, Eating, Toileting, and Personal Hygiene & Bathing. Review of R1's Progress Notes dated 04/17/23 at 11:41 AM, revealed Resident D/C from facility on 4/14/23. Review of R1's Progress Notes dated 04/13/23 at 2:19 PM, revealed, Patient seen today for NP discharge visit patient will be discharged from facility by himself to a hotel. He will be discharged with home health services MSA and he will need skilled nurse services, HHA, PT, SN, and OT . Prescription given for oxygen at 4 L/min via nasal cannula continuously for history of COPD. Facility social worker also informed that patient will need oxygen in place at his home setting prior to discharge from facility. Review of R1's Progress Notes dated 04/14/23 at 1:00 AM revealed patient seen today for NP discharge visit patient will be discharged from facility by himself to a hotel. He will be discharged with home health services MSA and he will need skilled nurse services, HHA, PT, SN, and OT. Patient has mobility limitations preventing the patient from completing ADL's. and I am extremely concerned over patient discharge but he is competent to make this decision. He is high risk for repeat hospitalization. Frankly I think he should begin with home health and probably transition to palliative care since his pulmonary disease is end-stage. He is malnourished with a hypermetabolic state. He is aware of the risk. Medications were reviewed and reconciled. During an interview on 04/09/24 at 10:47 AM, the Social Services Director (SSD) stated that R1 was discharged due to him not wanting to be here anymore and R1 had expressed the facility was not getting his money. SSD also states that R1 was discharged to a motel, and that he did not sign an AMA (against medical advice) and during his admission he was not compliant with wearing his oxygen. Lastly the SSD states that they focus on resident rights and choices when discharge planning and if it is a safe place, they will discharge resident. Review of an email from Home Health to the facility dated 04/09/24 at 5:04 PM, revealed, Received referral from [facility representative] for [R1] to be seen on MSA Home Health services on 04/13/23. However Patient could not be admitted to our services due to returning to [hospital] on 4/14/23. Patient not admitted to MSA Home Health. During an interview on 04/09/24 at 11:44 AM, the Director of Nursing (DON) stated that R1 knew where he wanted to go and that all she can remember about his discharge is how ugly he was towards the staff. The DON further stated that upon R1's arrival at the motel, the transportation driver called 911 and he was then taken to the hospital. R1 was not offered an AMA, nor did he sign one. During an interview on 04/09/24 at 1:36 PM, the Transport Driver (TD) stated that during transport of R1 to the motel, he had complained about not being able to breathe but that he was excited to go to the motel. Upon arrival at the motel the owner of the motel stated that R1 could not stay there without someone staying with him due to his condition. The TD then placed a call to 911 as a nurse on the transport van turned up his oxygen and was attending to his needs. The TD could not confirm if R1 had medications with him but could confirm that he had an Oxygen tank, tubing, wheelchair, and various personal items in a bag. During an interview on 04/09/24 at 1:50 PM, the Former Medical Director (FMD) stated that, he had multiple concerns with the facility regarding discharging residents who had issues with funding. The FMD also stated that he had concerns with the discharge of R1 and had noted those concerns in his physician note. The FMD could not remember if an IDT meeting was held prior to R1's discharge, nor could he comment on R1's discharge to the motel. Interview with R1 attempted but unsuccessful due to phone no longer connected. Interview with transport nurse attempted but unsuccessful due to phone no longer connected. On 04/19/24 at 10:41 AM, the facility provided an IJ Removal plan, which included the following: Immediate Actions Taken: -MD notified of lJ issued. -Re- education provided to SSD and DON by RDCS on 4-9-24 to ensure that all discharges from the facility are safe and that all documentation is in place. -ADHOC QA meeting held (see below) -Resident 1 no longer resides at the facility -Audit of all discharges in last 30 days complete by RDCS on 4-9-24 to ensure all discharges were safe and all documentation present. There were no concerns identified with any other residents. ADHOC QA Meeting Held 4-9-24 Audits of all discharges in last 30 days was reviewed by RDCS on 4-9-24 to ensure all were safe discharges and all documentation in place. All discharges will be reviewed and discussed by IDT team including Administrator prior to to discharge occurring to ensure that all documentation is complete and the discharge is deemed safe. Re-education was provided to SS, DON and Administrator by RDCS on 4-9-24 to ensure all discharges are safe and that all documentation and services needed are in place. Ongoing Monitoring to Continue: -All discharges are discussed daily in stand up meeting at facility as well as during IPOC (daily clinical review) and PDPM (review of skilled stay/short term residents). -All discharges are reviewed with MD prior to discharge to ensure all orders and any services needed are ordered and provided. -All discharges with any concerns r/t resident safety or well being will be discussed and APS referrals made as needed. -Ongoing monitoring and discussion of discharges will betaken thru QA meetings to discuss ongoing need for monitoring. -Audits of all discharges will beconducted weekly x 4 weeks and monthly x 2 months then random thereafter and report discussed with QA committee. The above components have been implemented as of 4-9-24 by 5pm