**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of the facility incident logs, review of facility fall investigations, emergency medical services (EMS), police records, police body camera (cam) footage, hospital records , observations, and interviews, the facility failed to provide supervision to prevent recurrent falls, review and revise the Care Plan, and implement fall interventions for 1 Resident (Resident #1) of 7 residents reviewed for falls. Resident #1, a severely cognitively impaired resident with a history of 6 falls since he admitted to the facility on [DATE], fell on 2/17/2024 and staff were unaware he had fallen until they were notified by police officers who responded to a call for a welfare check. Resident #1 was unable to reach facility staff and called a friend to ask for help. The friend notified law enforcement after he called the facility 10-12 times with no answer. The facility failed to review and revise the Care Plan and implement an intervention following the fall on 2/17/2024. On 2/27/2024, 10 days later, Resident #1 fell again and sustained a hip fracture. The facility's failure placed Resident #1 in an Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to resident) when he fell on 2/27/2024 and sustained a hip fracture. The Facility Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional [NAME] President were notified of the IJ on 4/2/2024 at 8:00 PM, in the conference room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which is substandard quality of care. The IJ began on 2/17/2024 and continued through 4/3/2024. The IJ ended on 4/4/2024 and was removed on site. An acceptable Removal Plan which removed the immediacy was provided by the facility 4/4/2024. Noncompliance continues at F-689 at a scope and severity of D. The corrective actions were validated on site by the surveyor on 4/5/2024 for F-689 . The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's undated policy titled Fall Prevention Program, showed .When any resident experiences a fall, the facility will .assess the resident .complete an incident report .review the resident's care plan and update as indicated . Review of the facility policy titled, Falls, revised 11/8/2022, revealed .The intent of this requirement is to ensure the facility provides .supervision .to each resident to prevent avoidable accidents . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Pain in Thoracic Spine, Difficulty Walking, Severe Malnutrition, Chronic Obstructive Pulmonary Disease, Dementia, with Behavioral Disturbances, Atrial Fibrillation, Long Term Use of Anticoagulants, and Acute and Chronic Respiratory Failure with Hypoxia. Review of the admission fall risk assessment dated [DATE] showed Resident #1 was considered at a high risk for falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status Score (BIMS) of 7 out of 15 which indicated Resident #1 had severe cognitive impairment. Resident #1 required substantial to maximum assistance of 1 or 2 staff members for all activities of daily living. Review of the facility incident logs dated 1/1/2024 to 3/27/2024, showed the facility documented Resident #1 fell on 1/23/2024, 1/29/2024, 2/14/2024, 2/16/2024, and 2/27/224. Continued review showed a fall which occurred on 2/17/2024 had not been documented on the incident log. Review of the care plan for Resident #1 dated 1/22/2024, showed .Fall Prevention Care Plan .Resident has had actual falls including with injury .at risk for additional falls related to weakness, poor safety awareness and impaired cognition . Continued review of the care plan showed the facility implemented the interventions after falls as follows: 1/23/2024 (no injury noted) .Keep frequently used items in reach . 1/29/2024 (skin tear left elbow, reddened area to chin, treatment administered) .offer rest period between lunch and dinner as resident will accept . 2/15/2024 (no injury noted) .offer toileting before dinner as resident will accept . 2/16/2024 (dislodged indwelling urinary catheter, skin tear to right thumb/hand, skin tears to right shin, transferred to hospital) . fall mats at bedside . 2/17/2024 No documentation a fall occurred; no new fall interventions were implemented. 2/27/2024 Resident #1 had a fall sustaining a right hip fracture and was transported to the hospital. 3/5/2024 .Have resident in high traffic areas while up in wheelchair . Review of the nursing notes for 2/16/2024, showed .[Resident #1] observed in the floor of the hallway yelling for help .blood noted on ground from his RLL [right lower leg] and right hand .Resident laying with head against the door to his room and legs out in the hallway .catheter bag [indwelling urinary catheter] still attached to bed .Resident stated I fell and I don't know what happened .cleaned and bandaged skin tears .[indwelling urinary catheter] reattached to catheter bag called EMS to transport to ER [emergency room] for evaluation due to head injury on blood thinners [anticoagulants] . Review of the EMS records for Resident #1 dated 2/16/2024, showed .Injury to hand [primary] .falls .2/16/2024 .dispatched to scene .on arrival received report from nurse .patient found on floor .concerned for head injury .patient on blood thinners .pulled out [indwelling urinary catheter] at some point today .but they [facility staff] reinserted one .pt [patient] found in bed on arrival .has skin tear to LT [left shin] .thumb .bleeding controlled .placed on cot via [by way of] draw sheet .transported [to the hospital Emergency Room] . Review of the hospital records dated 2/16/2024 showed Resident #1 was treated in the ER for skin tears to the thumb and shins. Resident #1 underwent neuroimaging [Computed tomography or CT Scan] which revealed no evidence of acute head injury or spinal injuries. Resident #1 was diagnosed with a severe Urinary Tract Infection (UTI) and fall related injuries. The indwelling urinary catheter was replaced in the emergency room. The resident returned to the nursing home with diagnoses of Fall from Standing, Multiple Skin Tears, a Complicated UTI with orders for antibiotics to treat the UTI, fall prevention instructions and wound care instructions. Review of the care plan revised 2/16/2024, showed Resident #1 had a new fall intervention for a floor fall mat at the bedside. Review of the Police Department Preliminary Investigative Report dated 2/17/2024, showed at 7:23 PM, a friend of Resident #1 called 911 and asked for a welfare check on Resident #1. The 911 caller stated Resident #1 had called him from the facility and informed the caller he had fallen to the floor, was on his back, and his calls for help [of the facility staff] had gone unanswered. Police officers arrived to the facility at 7:25 PM.Upon arrival officers made contact with [Resident #1] [at 7:30 PM] in room [Resident #1's room] in his bed .[Resident #1] stated he had not seen a nurse in over an hour and a half and that he did fall a while before officers got there .pushed his emergency button but no one came to help him .while officers were on the scene we did not see any nurses throughout the rehab .[Resident #1] was bleeding all over both of his arms, his legs, and possibly his back .There was blood in his bed, on the floor from his bed to the heating and air unit, all over the heating and air unit itself, across the floor to the doorway and on the wall and door .[Resident #1] requested an ambulance and wanted to go to the hospital .he was transported .by .[ambulance] to [hospital] .Just before the ambulance arrive to the rehab, a couple of nurses finally arrived and stated they did not know anything about [Resident #1] falling or bleeding everywhere. The nurses wanted to clean up [Resident #1's] wounds and the room before the ambulance arrived, and .[Officer #1 and Officer #2] .both told the nurses to leave things the way they were so paramedics could see the injuries . Review of police body cam footage of the incident, time stamped and dated 2/17/2024, showed both police officers who responded to the 911 call activated body cams immediately upon entering the facility lobby at 7:30 PM (the police officers had knowledge of the key access code of the locked keyless entry pad to the front lobby doors). Body cam footage from both officers showed no staff members were visible anywhere in the facility as they walked to Resident #1's room from the front lobby and made initial contact with the resident at 7:30 PM. Resident #1 was observed in his bed which was at normal height (approximately between thigh and hip high and not lowered as documented in the nursing notes) when the police officers arrived. Resident #1 was observed on the camera stating to the officers he had fallen and wished to be taken to a hospital. EMS was summoned by radio by the police officers at 7:34 PM. Officer #1 left Resident #1's room at 7:35 PM, walked back to the lobby to await the ambulance and no facility staff were visible anywhere in the facility. Officer #1's footage showed she awaited the ambulance in the front lobby and was not approached by any staff members. At 7:50 PM (approximately 20 minutes after arrival to the facility) Registered Nurse (RN #1) made contact with Officer #1, and asked if she could help the officer, and the officer explained why she was there, and that Resident #1 had fallen and an ambulance had been called for the resident. Review of body cam footage from Police Officer #2, showed at 7:30 PM, Resident #1 informed the police officers he called his friend to request an ambulance after he had fallen and felt shaky and was itching. The footage showed at 7:32 PM, Resident #1 again informed the police officers he had fallen. Officer #2 remained with Resident #1 continuously throughout the incident [without staff knowledge]. Further review showed Resident #1 stated he had been in the floor and had not spoken to anyone [facility staff] since he fell. Resident #1 described to Officer #2 how he pulled himself from the floor onto his knees grabbing onto the AC unit adjacent to his bed. Officer #2's body cam footage showed the police officer inspected the entire room and observed dried blood on the HVAC (AC) unit, dried blood spatter noted on the fall mat beside the bed adjacent to the HVAC unit, dried blood smear on the door trim beside the door at the entrance to Resident #1's room, dried blood spatter on the back of Resident #1's room door, and dried blood spatter on the flooring between the doorway and Resident #1's bed. Officer #2's body cam footage showed Resident #1 had a large skin tear on the left elbow with bright red blood. Close up footage of Resident #1's skin injuries showed the skin tear on the left elbow had rolled up skin on the upper aspect of the wound. No dressing was visible on the left arm. Bright red blood was visible on the back of Resident #1's right elbow with another large skin tear. No dressing was visible on the wounds. Bright red blood was also noted on Resident #1's clothing near Resident #1's waist on the right side and was also visible on the resident's bedding. The officer questioned Resident #1 about the observation of blood on his pants and Resident #1 stated he had pain in his back and felt he had injured his back. Continued review of Officer #2's body cam footage showed as staff entered the room with Officer #1 (approximately 20 minutes after the police officers arrived at the facility), both officer's informed them Resident #1 had stated a fall, showed staff evidence of his injuries and the blood spatter throughout the room. Officer #1 was observed pointing out to staff members they were standing in dried blood on the floor. Staff stated to police they were unaware Resident #1 had fallen. Review of Officer #1's body cam footage showed at 7:54 PM staff members approached the officer in the hallway outside Resident #1's door and requested permission to clean [Resident #1] up before transport to the hospital. The officers advised staff an ambulance was in route and not to clean Resident #1's wounds, as EMT's needed to see the resident's injuries and the condition of the room as it was found by the police. Further review of Officer #2's body cam footage showed EMS personnel arrived at the resident's room at 7:55 PM and immediately greeted Resident #1 by his first name. EMS asked the resident if he wanted to go the hospital. Resident #1 stated he did and explained he had fallen and had been injured. Review of Nursing Notes dated 2/17/2024 at 10:04 PM, showed .[Resident #1] in bed in low position with blood noted to left elbow area, alert no complaints of pain, will send to emergency room for evaluation, family members aware . Review of the Police Department Preliminary Investigative Report for Resident #1 dated 2/17/2024, the detective notes revealed .On 2/18/2024, I [Detective] reviewed the officers body camera from this incident .[Officer #1] arrived and for the time the camera was on there was no nurses observed in the hallways .[Resident #1] was in the bed at normal height [and not in a low bed as indicated by the nurse's notes] in his room .[Resident #1] asked if she was the police and began telling her what happened .there was fresh blood on his shirt in the left elbow area, bed sheet, blanket and spatter on the AC .[Officer #1] asked how he [Resident #1] got back in bed and [Resident #1] stated he managed .later told officer that he [Resident #1] used the AC unit to get himself back up which is why it had blood on it .[Officer #1] asked if he [Resident #1] wanted an ambulance and he explicitly said yes .officer asked for his name and birthdate which he gave and spelled without issue .Officer .then went to the front door to await an ambulance .[Officer #1] waited at the front door approximately 15 minutes for the ambulance .went back toward the room and encountered two nurses in the hallway near [Resident #1's] room .One of the nurses asked if she could help her .She explained why she was there, which the nurses appeared to not be aware of .The nurses then entered the room and ask [Resident #1] what happened .one of the nurses said [Resident #1] fell yesterday also and had blood everywhere . Continued review showed .Another nurse returned and asked about going in the room and changing [Resident #1] .[Officer #1] told her not to, because an ambulance was enroute and they needed to see the state he was in . Review of the EMS documents dated 2/17/2024, showed .dispatched to pt [patient] [Resident #1] evaluation request by PD [police department] at [facility] .Upon arrival were led by law enforcement .pt was alert and oriented .stated he had fallen while trying to get to the bathroom .stated he had fallen approximately 1.5 hours ago and was eventually able to get himself back in bed .stated he wanted to go to the hospital .findings of an approximately 6 cm [centimeter] skin tear on left elbow and a 4 cm skin tear on right elbow. Review of the hospital emergency room records dated 2/17/2024, showed Resident #1 underwent laboratory studies, neuroimaging studies and treatment for additional skin tears at the hospital. Review of the triage notes showed, .This RN [Registered Nurse] spoke to the patient family friend [the 911 caller] .[911 caller] stated he called the nursing home approximately 10 to 15 times and ' .never got a response' .states when he could not get ahold of anyone he called the sheriffs office to do a welfare check .Wound care completed on patient's bilateral elbow skin tears and an upper back skin tear . Review of the hospital ER physician notes dated 2/17/2024, showed the physician had documented, .reportedly called family members and stated he had fallen .family .called police .police went to the facility .police then called EMS .patient [Resident #1] was seen here earlier this morning [late night of 2/16/2024 into early morning of 2/17/2024] and had a fall, was discharged to the facility on antibiotics .patient without acute traumatic findings on imaging .noted to have pulmonary infiltrate [Pneumonia] .spoke with patient's facility .they were strongly advised to closely monitor patient over the next few days given his increased fall risk .will discharge Fall prevention literature was included in discharge orders sent back to the facility. Review of the witness statement for RN #1 dated 2/17/2024, showed .Saw police officer outside door [Resident #1's room doorway] .stated he [Resident #1] had fallen and crawled to the door and been there for hours .Stated Resident called family and told them, family called police .[Resident #1] .lying in bed, noted blood to the left arm area .noted blood on air conditioner, minimal amount there and also on mat to the left side of the bed .noted small dried drops at the doorway and about a foot into hall .officer stated you are standing in the blood .From prior night fall [2/16/2024] reported to me by nurses that had him [provided care on the night of 2/16/2024] he had a dressing on left upper (arm) .and steri-strips to right thumb .rt [right] chin had steri strips applied .reported he had crawled to door that night .Nurse stated when he was in emergency room he stated he fell down some stairs . Review of Resident #1's medical record and care plan showed no new intervention had been implemented for the fall or after the resident returned from the hospital on 2/17/2024. Review of the facility document titled, Final Investigation, dated 2/21/2024, signed by the former Administrator showed .Background of the event .911 call placed by friend of [Resident #1] 2/17 [2/17/2024] approximately 7:30 PM .Resident told friend he had fallen and needed help and could not reach anyone [staff at the facility] .Injuries .No known injuries from this alleged event .this resident .with a history of falls and did have previous fall on 2/16/2024 .resulting in trip to the ER [emergency room] due to fall being unwitnessed .he did have skin injuries to the RLL [right lower limb] and right hand with skin tears to right elbow .Initial Report Summary .Facility nurse notified the Director of Nurses on 2/17 at approximately 8:00 PM that a 911 call had been made by the resident's friend alleging that he [Resident #1] had fallen and could not get help [from the facility staff] .They [Resident #1's family/friend] were concerned . Investigative Activity .Staff on that unit were interviewed regarding the alleged incident .It was determined the resident was in bed at the time of arrival of the EMS/police .There was no indication that he had fallen in that immediate time frame .they [the facility staff] had been in and out of the room throughout this shift to include delivery of meals .Investigative Activity: .Staff interviews made and statements gathered indicate no indication of a fall on this date [2/17/2024] . Based on record review and witness statements there was no fall on this date [2/17/2024] .The residents conversation with friend was most likely describing events of his previous fall [2/16/2024] .It is highly likely due to his unclear speech and dementia with a BIMs of 07 [severe cognitive impairment on scale of 7 out of 15] that the time frames and occurrences were not accurate .Conclusion .The facility camera system recorded events of that .time frame were conducted with [former DON] .[local detective] .and [TBI] [Tennessee Bureau of Investigations] [special agent] .that revealed there was no indication that the resident had fallen .The tape confirmed events surrounding care to include delivery of the evening meal .Based on the above mentioned information I [former Administrator] cannot substantiate that there was a fall, no wrong doing on behalf of the staff .on date of this alleged occurrence [2/17/2024] . Review of the facility ATTESTATION document dated 2/21/2024, signed by the former DON showed .Please accept this document as my attestation and is being submitted as evidentiary material related to the investigation being conducted for [Resident #1] related to 911 call on 2/17/2024 .This event was reported to me on 2/17/2024 via [by way of] telephone call at 7:55 PM by [Registered Nurse, RN #1] .[RN #1] notified me that there were officers here that said they had been called to check on [Resident #1] because he had told his friend that he was in the floor and didn't have help .Resident was in the bed resting when officers responded .I [former DON] asked [RN #1] when the last time he [Resident #1] was seen by staff and she [RN #1] stated he was seen when staff were picking up trays after the dinner time meal and he was resting in bed .and there was no concerns at that time .[RN #1] stated . to me [former DON] that she was told by police that they were waiting on EMS to take the resident to the ER to get checked out .Police told [RN #1] not to touch [Resident #1] that they wanted to send him [to the hospital] how he was .[RN #1] let me know that EMS had come and were picking him up within minutes of notifying me that the police had arrived .Continued review of the attestation document revealed .On 2/20/2023 TBI agent and local detective came to the facility in regard to the 2/17 [2/17/2024] 911 call .They asked me [former DON] what I knew about the event .I stated the above account and stated I had the statements in a folder in my desk .They asked for copies of the statements .Detective asked about cameras in the hallway outside [Resident #1's room] .I let her [Local Detective] know they [the camera footage] go back 3 days roughly 72 hours .we go review the footage from that time period police responded .SSD [Social Services Director] able to pull up camera footage from the area and time frame requested .when reviewing footage .it is seen that [Certified Nursing Assistant] [CNA #2] went to [Resident #1] room and picked up the dinner tray .[Resident #1] was never seen in the hallway or the doorway of his room from the time trays were given out at dinner to the time police responded .TBI agent and detective seemed to have no concerns . Review of the facility incident logs dated 1/1/2024 to 3/27/2024 showed the incident of 2/17/2024 had not been documented. Review of the nursing notes showed on 2/27/2024, Resident #1 had a witnessed fall from his wheelchair while seated in the hallway near the nursing station. Resident #1 complained of right hip pain and staff summoned EMS to the facility. Resident #1 was transferred back to the hospital by EMS for the third time in 10 days related to falls . Review of the EMS records dated 2/27/2024, showed EMS was dispatched to the facility due to a reported fall. On arrival they found Resident #1 in the hallway floor surrounded by staff. Resident #1 complained of right hip pain rated as 10/10. Resident #1 was examined by EMTs and transported to the hospital by ambulance. Review of the hospital records dated 2/27/2024, showed in the emergency room Resident #1 underwent Computer Assisted Tomography (CAT SCAN) which showed .on the right is an acute appearing intertrochanteric fracture with varus angulation and surrounding soft tissue swelling [a displaced fracture of the upper femur, hip fracture ] . Resident #1 was admitted to the hospital and underwent surgical repair of his fractured hip on 2/29/2024. Observation and interview on 3/27/2024 at 6:05 PM, showed Resident #1 lying in his bed at a regular height (between thigh and waist high). A single fall mat was on the left side of the bed between the bed and air conditioning unit. Resident #1 was confused but recalled falling several times at the facility. Resident #1 recalled one incident where he crawled to the doorway and was bleeding, and stated he had fallen into the wall and an ambulance came and transported him to the hospital. The resident stated one time he called his friend (the 911 caller) and showed the surveyor the cellular phone he used .I used this to call .because nobody [facility staff] comes . when you call for assistance. Resident #1 stated, .now I have fallen again, I broke my hip, I can't walk anymore, it's hopeless for me now . During an interview on 3/28/2024, the Interim Director of Nursing (DON) stated he became aware on 3/28/2024, the state and local law enforcement agents and Adult Protective Service Investigators had visited the facility and investigated the incident of 2/17/2024 for Resident #1. The DON reported he had reviewed facility files related to the matter with emails dated 2/21/2024 on the morning of 3/28/2024, and that was when he became aware the police had concerns about the incident. The DON reported the former DON and former Administrator had investigated the incident and determined there was no evidence Resident #1 fell on 2/17/2024. The Interim DON stated the incident occurred before his, the newly hired Assistant DON's, and the Interim Administrator's start of employment at the facility and they had not been informed of the allegations or specific facility findings related to the incident until the State Survey Agency had begun it's investigation on 3/27/2024. During a telephone interview on 4/1/2024 at 1:00 PM, the 911 caller of 2/17/2024, stated he was a friend of Resident #1 who along with his father had assumed surrogacy roles for Resident #1 because Resident #1 had no children of his own, or relatives in the United States. The 911 caller stated Resident #1 called him on the evening of 2/17/2024 (didn't recall exact time) but knew it was in the late afternoon or early evening hours and reported he had fallen from his bed, was on his back, had called out for help repeatedly and the facility staff had not responded to his calls for help. The 911 caller stated Resident #1 informed him he had been in the floor .over an hour . The 911 caller stated he then immediately attempted to call the facility on the main line, then called both wings in attempts to reach staff, between 10 and 12 times, and each time he called, the phone rang but went unanswered. At that point, he dialed 911 and requested police go to the facility for a welfare check on Resident #1 and the facility. During an interview on 4/1/2024 at 1:15 PM, Certified Nurse Aide (CNA) #3 stated on the night of the incident (2/17/2024), a majority of the patients on the wing were situated on the far end of the unit away from Resident #1's room and staff were on that end of the unit most of the shift. CNA #3 stated around the time of the incident, all 3 staff stationed on the unit were engaged with a family member of another resident. CNA #3 stated CNA #2 had collected Resident #1's meal tray around 6:15 to 6:30 PM that night and at that time the resident was in bed. CNA #2 confirmed she was not aware of the police officer on the unit until around 8:05 PM. (Police Officers entered Resident #1's room at 7:30 PM and left the unit with EMS at 8:03 PM per the body cam footage). CNA #3 stated she had not entered the resident's room during the incident or encountered Officer #2. CNA #3 stated after the incident she cleaned the resident's room and noted blood on the AC unit and floor mat beside the bed. CNA #3 described blood spatter on the AC [air conditioner] vent as appearing like a feather had painted it on the vents. CNA #3 confirmed staff were not aware police officer had entered the building or of Resident #1's fall until they were notified by the police officers. During an interview on 4/1/2024 at 2:10 PM, CNA #2 stated she had seen Resident #1 in his bed around 6:15 to 6:30 PM when she picked up his dinner tray. CNA #2 stated she lowered Resident #1's bed to the lowest setting (indicating lowered to the floor) after removing his tray as she was aware of his fall on 2/16/2024 (this is conflicting as to what was reflected on the police camera footage and police investigative report which stated the bed was at a regular height at approximately thigh to waist high). CNA #2 stated at that time Resident #1 was awake, in bed, and had an intact dressing on his left elbow (the police officer body camera footage showed no dressing or bandage on the resident's left elbow). CNA #2 confirmed she was unaware police had entered the unit until she went to answer a call light in a resident room next door to Resident #1 sometime between 7:00 and 7:30 PM (couldn't recall exact time). CNA #2 confirmed the nurse on duty was also not aware the police officers had entered the facility. CNA #2 stated she had not been in the resident's room or observed the resident after approximately 6:30 PM that evening and was not aware Resident #1 had fallen until the staff had been notified by the police officers. During an interview on 4/1/2024 at 2:45 PM, RN #1 stated she was the nurse on duty at the time of the incident on 2/17/2024. RN #1 corroborated CNA #2 and #3's account of issues with a family member on the far end of the unit at the time the incident with Resident #1 had arisen. RN #1 stated only 2 residents were situated on the rear hallway (Resident #1 and his neighbor in the next room) the rest of the unit's residents were on the front hall. RN #1 was unable to recall the census on the unit on 2/17/2024 but knew it was at least 20 residents. RN #1 stated she had not heard the unit telephone ring that evening but added the only phone was located at the nursing station and could not be heard from the hallways or clinical spaces. RN #1 stated she observed police officers sometime between 6:30 and 7:00 PM but could not recall the exact time (Police entered the unit at 7:30 PM). RN #1 stated after she became aware the police officers had found Resident #1, she immediately telephoned the former Director of Nursing (DON) and informed her of the nature of the situation while police were still on the premises. RN #1 stated she informed the DON that Resident #1 had fallen again and appeared to be injured. RN #1 stated she was aware CNA #2 had last seen the resident around 6:15 PM to 6:30 PM (approximately 1 - 1 hour and 15 minutes before the fall) that evening and the resident had been in bed. RN #1 stated she believed Resident #1 had fallen, and confirmed the fall went undetected by the facility staff until the police arrived. During an interview on 4/1/2024 at 3:50 PM, the Interim DON confirmed the facility Resident #1 had suffered a fall with related injuries on 2/16/2024 and 2/17/2024. The DON confirmed the facility failed to review, revise, and update the care plan to implement interventions in response to Resident #1's fall on 2/17/2024 and the resident had received a serious injury (fractured hip) from the fall on 2/27/2024. The DON confirmed the facility failed to protect Resident #1 from a serious injury related to falls. The DON further confirmed the facility investigation performed on 2/21/2024 by the former [NAME] and former Administrator appeared incomplete and the facility incident log did not include the unwitnessed fall. During an observation and interview on 4/1/2024 at 5:45 PM, showed Resident #1 was on 1 to 1 staff supervision. The DON stated new interventions and enhanced supervision of Resident #1 had been implemented on 3/28/2024, after the corporate office had reviewed the incident which had occurred on 2/17/2024 and due to signs of agitation and increased confusion, Resident #1's room had been moved closer to the nursing station, the bed was lowered to its maximum low setting, a scoop mattress (specialty mattress with raised borders)[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, incident logs, review of census and staffing data review, time punch reports review, police reports and police officer body camera (cam) video footage review, and interviews, the facility failed to maintain sufficient nurse staffing levels on 1 of 2 units on the night of 2/17/2024. The facility's failure to maintain sufficient nurse staffing levels to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of residents on 1 of units (The Mountain Unit) on 2/17/2024 of 60 days reviewed which resulted in facility staff not detecting a fall for Resident #1 for an unspecified amount of time. The facility's failure to maintain safe staffing levels placed Resident #1 in an Immediate Jeopardy (IJ) situation, (A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to result in serious injury, harm, impairment, or death to a resident, and must be immediately corrected). The facility's failure to maintain safe staffing levels had the potential to impact all 78 residents of the facility. The Facility Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional [NAME] President were notified of the IJ on 4/2/2024 at 8:00 PM, in the conference room. The facility was cited Immediate Jeopardy at F-725 at a scope and severity of J. The IJ began on 2/17/2024 and continued through 4/3/2024. The IJ ended on 4/4/2024 and was removed on site. An acceptable Removal Plan which removed the immediacy was provided by the facility on 4/4/2024 for F-725. The corrective actions were validated on site by the surveyor on 4/5/2024 for F-725. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's undated policy titled, Nursing Services and Sufficient Staff, showed .It is the policy of this facility to provide sufficient staff to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis .Licensed Nurses .Other nursing personnel including .nurse aides .Providing care includes .responding to resident needs . Review of the medical record showed Resident #1 was admitted to the facility on [DATE], with diagnoses including Pain in Thoracic Spine, Difficulty Walking, Severe Malnutrition, Chronic Obstructive Pulmonary Disease, Dementia, with Other Behavioral Disturbances, Atrial Fibrillation, Long Term Use of Anticoagulants, and Acute and Chronic Respiratory Failure with Hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status Score (BIMS) of 7 out of 15 which indicated Resident #1 had severe cognitive impairment. Resident #1 required substantial to maximum assistance of 1 or 2 staff members for all activities of daily living. Review of the facility nursing notes dated 2/16/2024, showed Resident #1 had been transported to a local hospital due to a fall with related injuries. Review of the care plan showed Resident #1 had a fall on 2/16/2024 and a new intervention of a fall mat to the bedside was implemented. Review of facility documentation dated 2/17/2024, showed the facility census on the unit in which Resident #1 resided was 27 with staffing of 1 Registered Nurse and 2 Certified Nurse Aides. Continued review showed the entire facility census was 75 with a total staffing pattern of 2 nurses and 5 Certified Nurse Aides. Review of the staffing data and resident census for Resident #1's unit (The Mountain Unit) dated 2/17/2024, showed on the night of the incident (2/17/2024), the unit was originally scheduled to have been staffed with 2 Licensed Practical Nurses (LPNs) and 2 Certified Nurse Aides (CNAs) for 27 residents. Review of the time punch reports for the Mountain Unit, dated 2/17/2024, showed an agency LPN had not reported for duty as scheduled. The unit was staffed with 1 Registered Nurse (RN #1) and 2 CNAs (CNAs #2 and #3) for 27 residents. The open position from the agency nurse went unfilled. Review of the Police Department Preliminary Investigative Report (police report) dated 2/17/2024 at 7:23 PM, showed a friend of Resident #1 called 911 and asked for a welfare check on Resident #1. The 911 caller stated Resident #1 had called him from the facility and stated he had fallen to the floor, was on his back, and his calls for help had not been answered by the staff. The 911 caller informed 911 he had repeatedly attempted to call the facility (10-15 times), but the phone went unanswered. Police arrived to the facility at 7:25 PM. Continued review of the police report showed, .Upon arrival officers made contact with [Resident #1] in room [Resident #1's room] in his bed .[Resident #1] stated he had not seen a nurse in over an hour and a half and that he did fall a while before officers got there .pushed his emergency button but no one came to help him .while officers were on the scene we did not see any nurses throughout the rehab . Resident #1 was bleeding all over both of his arms, his legs, and possibly his back. There was blood in the resident's bed, on the floor from his bed to the heating and air unit (AC unit), all over the heating and air unit itself, across the floor to the doorway and on the wall and the resident's room door. Resident #1 was transported by an ambulance to the hospital. Review of police body cam footage of the incident, time stamped and dated 2/17/2024, showed both police officers who responded to the 911 call activated their body cameras immediately upon entering the facility lobby at 7:30 PM (Police Officer had knowledge of the pass code for the digital keyless entry for the front door of the facility) Body Cam footage from both officers showed no staff members were visible anywhere in the facility as they walked to Resident #1's room from the front lobby and made initial contact with the resident at 7:30 PM in his room. Resident #1 was observed in his bed which was at normal height (approximately between thigh and hip high) (not lowered as documented in the nursing notes) when officers arrived. EMS was summoned by police radio at 7:34 PM. Officer #1 left Resident #1's room at 7:35 PM, walked back to the lobby to await the ambulance and at no time were facility staff visible anywhere in the facility. 15 minutes later, at 7:50 PM (approximately 20 minutes after arrival to the facility), Registered Nurse (RN) #1 approached Officer #1, asked if she could help the officer, and the officer explained why she was there, and that Resident #1 had fallen. Continued review of body cam footage from Officer #2, showed at 7:30 PM, Resident #1 informed the police he had called his friend for help after he had fallen and felt shaky and was itching. The body cam footage showed Resident #1 stated he had fallen and . need to get out of here . Further review showed Resident #1 expressed he had fallen to Officer #2 again at 7:35 PM and stated he had been in the floor and had not spoken to anyone [facility staff] since he fell. Resident #1 then described to Officer #2 how he pulled himself from the floor onto his knees grabbing onto the AC unit adjacent to his bed. Officer #2's body cam footage showed Resident #1 had a large skin tear on the left elbow with bright red blood and a skin tear on the left elbow. Bright red blood was visible on the back of Resident #1's right elbow with another substantial skin tear. Continued review of Officer #2's body cam footage showed as staff entered the room with Officer #1, both officer's informed them Resident #1 reported a fall, showed staff evidence of his injuries and the blood spatter throughout the room. In the background of the police body cam footage, staff stated to police they were unaware Resident #1 had fallen. Staff were also heard to tell officers .there are only 3 of us [facility staff] here . Review of Officer #1's body cam footage showed at 7:54 PM staff members approached the officer in the hallway outside Resident #1's door and requested permission to clean up [Resident #1's] wounds and the room before transport to the hospital. The officer advised staff an ambulance was enroute and not to clean Resident #1, as EMT's needed to see the resident's injuries and the room as found by the police officers. Further review of Officer #2's body cam footage showed EMS personnel arrived at the room at 7:55 PM and transported the resident to the hospital. Review of the Police Department Preliminary Investigative Report showed the detective notes dated 2/18/2024, revealed . On 2/18/2024, I [local detective] reviewed the officers body camera from this incident .[Officer #1] arrived and for the time the camera was on there was no nurses observed in the hallways .[Resident #1] was in the bed at normal height in his room .officer asked for his [Resident #1's] name and birthdate which he gave and spelled without issue .[Officer #1] .then went to the front door to await an ambulance .[Officer #1] waited at the front door approximately 15 minutes for the ambulance which still had not arrived .went back toward the room and encountered two nurses in the hallway near [Resident #1's] room .One of the nurses asked if she could help her .She explained why she was there, which the nurses appeared to not be aware of .The nurses then entered the room and ask [Resident #1] what happened .In the background one of the nurses said [Resident #1] fell yesterday also and had blood everywhere . Continued review showed, .Another nurse returned and asked about going in the room and changing [Resident #1] .[Officer #1] told her not to, because an ambulance was enroute and they needed to see the state he was in . Review of the detective notes on the Preliminary Investigation Report showed an entry dated 2/22/2024, which read, .Agent .and I went to [the facility] on 2/20/2024, and met with Administrator [the former Administrator] .She stated she was aware of an incident, but did not know all the details .then went to get the Director of Nursing [the former DON] .[former DON] .stated written statements were collected from the three nurses who were working [on the evening of 2/17/2024] .The statements indicated the nurses were on that floor and no officer ever came and sought them out .Also that they offered to treat [Resident #1] but the officer would not allow them to .I [local detective] asked about video since there is a camera just outside his [Resident #1] door .Originally I was told it only holds 3 days and the time was up .Later, I learned that it was still on the system .We watched the video which showed a nurse picking up his [Resident #1] tray at approximately 6:15 PM and there was not another nurse went into the room or was even in that hallway prior to the officers arrival at approximately 7:25 PM [approximately 1 hour and 10 minutes later] .This investigation remains ongoing . During an interview on 3/28/204 at 3:15 PM, the facility scheduler, Certified Nurse Aide (CNA) #1 stated the facility used agency staff frequently to fill open shifts. CNA #1 stated in her estimation, around 30 to 40 percent of the facility shifts were filled by contracted agency employees from 2 online staffing services. CNA #1 stated it was not uncommon for employees of the online agencies to accept shift assignments made a week in advance, then cancel their shift with little or no advance notice on the day they were to report for duty. CNA #1 stated she frequently utilized the facility's own employees to cover shifts when agency personnel gave no notice (no call no show) and failed to report to work as scheduled. CNA #1 stated the facility had filed complaints with both online nursing agencies related to this problem repeatedly, but it had little or no recourse other than placing agency employees who failed to come to work as scheduled on do not return list. CNA #1 stated the facility's normal staffing pattern was for 2 nurses and at least 2 CNAs on every unit on night shifts, and 2 nurses and at least 4 CNAs on day shifts. CNA #1 confirmed on the night of 2/17/2024, an agency nurse, had not reported for duty as scheduled with no advance notice. CNA #1 stated she attempted to fill the vacancy with both agency and facility personnel but was unsuccessful. CNA #1 stated on the evening of 2/17/2024, she informed the former DON, The Mountain Unit was staffed with only 1 nurse and 2 CNAs (didn't recall the exact time) and was short staffed, but the DON could not fill the vacancy either. CNA #1 stated no member of the former nursing leadership team came in to work to fill the vacancy when the DON failed to procure a replacement nurse. CNA #1 confirmed the facility had multiple nursing leadership personnel who could have come into work to fill the open slot in the schedule which included the DON, Assistant DON, an MDS Nurse, or the Infection Control Nurse. The scheduler confirmed on the night of 2/17/2024, The Mountain Unit was understaffed. During an interview on 3/28/2024 at 5:56 PM, CNA #4 stated it was not uncommon for agency staff to fail to report for duty as scheduled or to report for duty late. CNA #4 stated she had worked overtime to cover unplanned absences around twice per pay period due to being understaffed. CNA #4 stated the staff absences and understaffing had been reported to administration. During an interview on 3/28/2024 at 6:00 PM, LPN #2 stated she occasionally worked overtime to cover unplanned contract staff absences. LPN #2 stated when agency personnel failed to report for duty the units were understaffed. LPN #2 stated the staff absences and the understaffing had been reported to administration, repeatedly. During an interview on 3/28/2024 at 6:02 PM, CNA #7 stated she had complained several times to the former facility leadership including the former DON and the former Administrator about the issue with reliability of contracted employees and impacts on scheduling and the low staffing levels with the difficulty in providing timely care to all the residents when the facility went understaffed. During an interview on 4/1/2024 at 1:00 PM, the 911 caller reported he was a friend of Resident #1. The 911 caller stated Resident #1 had telephoned him that evening (2/17/2024) (didn't recall exact time) and told him he had fallen, was in the floor and his cries for help went unanswered by staff. The 911 caller stated he attempted to call the facility's main line, and both unit phone numbers at the facility 10 to 15 times over several minutes, in efforts to reach staff and the calls went unanswered. The 911 caller stated after that, he became more concerned for Resident #1 and the facility after Resident #1 failed to answer his phone on return call. The 911 caller immediately dialed 911 and asked for a welfare check on the resident. The 911 caller stated he visited Resident #1 occasionally but never attempted visits after 5:30 PM as the lobby was usually unattended, the front door was locked and staff frequently did not answer the door or the phone, and no staff were ever near the lobby to open the front door, which was kept locked by a digital keypad-controlled lock and the caller did not have knowledge of the pass code to enter the facility. The 911 caller stated he had stopped visiting in the evenings for that reason. The 911 caller stated he felt the facility was always understaffed and was concerned about the situation. During an interview on 4/1/2024 at 1:15 PM, CNA #3 (who was on duty on the night of the incident on The Mountain Unit) stated the unit was understaffed on the night of 2/17/2024. CNA #3 stated she recalled the incident and described the entire shift as apocalyptic due to issues on the unit further compounded by the short staffing. CNA #3 stated most of the Residents on the unit were situated near the front of the unit, while Resident #1 was located near the rear of the unit with only one other resident. CNA #3 stated she had left the unit for around 10 to 15 minutes sometime between 6:45 and 7:00 PM that evening to get fast food for another Resident after a family member had made the demand. During that time, only the nurse (RN #1) and 1 CNA (CNA #2) staffed the unit. CNA #3 stated she was aware her co-worker CNA #2, had collected Resident #1's dinner tray around 6:15 to 6:30 PM and the resident had been in bed at that time. CNA #3 estimated there were around 30 residents on the unit on 2/17/2024. CNA #3 stated she was unaware police had entered the facility due to she and CNA #2 being engaged with other residents, most of whom required 2 persons assistance and who resided on the other end of the unit. CNA #3 stated due to an agency nurse absence, both CNAs were responsible for between 15 to 17 residents each and there was only 1 nurse on the unit that night. CNA #3 stated the unscheduled absences and agency personnel not reporting to work as scheduled was a common occurrence. CNA #3 confirmed she was not aware of the exact time police arrived to the unit on 2/17/2024, and estimated it to be around 8:05 PM. CNA #3 stated she believed the understaffing contributed to staff's failure to notice police officers when they arrived or to detect Resident #1's fall. During an interview on 4/1/2024 at 2:15 PM, CNA #2 stated on 2/17/2024 she last saw Resident #1 between 6:15 and 6:30 PM when she picked up his dinner tray. CNA #2 stated she lowered Resident #1's bed to low setting at that time (this is inconsistent to police body cam footage and police investigative notes which indicated Resident #1's bed was at a normal height ) (approximately between thigh and hip high). CNA#2 stated Resident #2 had a bandage on his left elbow when she last saw him. (This was inconsistent with body camera footage observed by the State Agency (SA) which showed no evidence of dressings on Resident #1's left elbow when police entered the room on the night of 2/17/2024). CNA #2 stated on the night of the incident there were around 30 residents on the unit, then stated many were sick and required 2 staff assistance. CNA #2 stated the staffing pattern on 2/17/2024 of only 1 nurse and 2 CNAs made it difficult for CNAs to complete all assigned duties or monitor the entire unit. CNA #2 stated it was common for scheduled agency personnel to not report for duty and give no notice of their pending absence. CNA #2 stated she and other facility CNAs had repeatedly complained to the scheduler, the former DON, and the former Administrator of their concerns with agency personnel and understaffing when agency personnel failed to report for duty. CNA #2 stated facility employees volunteered for overtime to fill uncovered staff absences but could not meet every need. CNA #2 stated on 2/17/2024 she had not checked on Resident #1 again after picking up his dinner tray around 6:15-6:30 PM on the night of the occurrence. CNA #2 then explained she and the other CNA were providing care to others on the front section of the unit and were unaware Resident #1 had fallen. CNA #2 stated she had not seen the police officers arrive to the unit but noted their presence sometime between 7:00 and 7:30 PM (the police officers arrived to the facility at 7:30 PM and went unnoticed by staff for 20 minutes). CNA #2 confirmed CNA #3 had left the unit around 6:00 PM, to obtain food in efforts to calm another resident's family member, and stated CNA #3 was gone around 20 minutes, which left only her and the nurse on the unit. During an interview on 4/1/2024 at 2:45 PM, RN #1 stated on 2/17/2024 at the time of the incident with Resident #1, she was on the front wing of the unit administering tube feedings and medications to a resident and did not see police enter the facility. RN #1 stated the majority of residents on the Mountain Unit were situated on the front wing of the unit. RN #1 stated Resident #1 and one other resident remained on the rear wing of the unit, confirmed she was the only nurse on duty, and estimated she was assigned .at least 20 . residents. RN #1 corroborated CNA #2 and CNA #3's accounts of an angry family member monopolizing staff attention and CNA #3 had left the unit for around .10 to 15 minutes . to acquire chicken nuggets from a nearby fast-food restaurant in attempts to appease a resident's family member, which left only RN #1 and CNA #2 on the unit. RN #1 stated she estimated she first saw the police officers enter the unit around 7:30 PM as she rounded the nursing station that night on the way to Resident #1's room. (Body cam footage showed this occurred at 7:50 PM, approximately 20 minutes after police arrival to the facility) and asked the Officer if she could help her. Continued interview revealed RN #1 confirmed she did not hear the unit telephone ring that night and reported the phones could not be heard from the hallway and no mobile handsets were in use at the facility. RN #1 stated she had expressed concerns about that to the former DON and Administrator several times before 2/17/2024, to no avail. RN #1 stated problems with agency staffing at the facility were problematic due to frequent no call no shows. RN #1 stated when agency staff failed to report as scheduled the unit was understaffed. RN #1 confirmed on 2/17/2024 an agency nurse failed to report for duty as scheduled. RN #1 stated she had expressed concerns related to understaffing and the reliability of contracted employees to the former Administrator and DON several times before the 2/17/2024 incident and felt the understaffing may have attributed to the staff being unaware of Resident #1's fall. During an interview on 4/1/2024 at 3:50 PM, the DON stated the facility's leadership team in place on 2/17/2024 were no longer employed at the facility. The DON stated this included the former Administrator, DON, Assistant Director of Nursing (ADON), MDS Nurse, and Infection Control Nurse. The DON stated after additional quality assurance reviews of Resident #1's incident on 2/17/2024 were completed by the current leadership team on 3/28/2024 (1 day after the State Agency entered the facility and 40 days after the incident), the facility had reviewed the staffing models and data and had put measures in place to aid the staffing issues. The DON confirmed on 2/17/2024 the Mountain Unit was understaffed but was unable to verify if she felt it attributed to Resident #1's fall. Refer to F-657 and F-689. Allegation of Compliance (AOC) Removal Plan for F725 The facility's corrective actions for the removal plan were issued to the surveyor on 4/3/2024. The corrective action plan included the following: 1. The Chief Regulatory and Compliance Officer provided training to the Administrator, DON, and ADON about their responsibility to ensure sufficient staffing at all times to assure resident safety. 2. The facility leadership and members of the Governing Body reviewed the facility's recruitment and retention program. 3. On 4/2/2024, the Administrator, DON, ADON, members of the Governing Body and Corporate Staff reviewed the allegations (2/17/2024 incident with Resident #1), discussed immediate actions and removal plan. 4. Policies and procedures were reviewed by the DON, ADON, Administrator, VP of Clinical Service and VP of Regulator Compliance. No changes were made to the current policies and procedures. 5. To ensure compliance with staffing requirements the DON, ADON, Administrator, and staff Scheduler will review daily staffing to ensure sufficient staffing at all times. a. When there are nurse or Certified Nursing Assistant (CNA) call ins, facility employees are asked to work with incentives offered and/or request for agency staff. 6. Members of the Governing Body and Corporate team will conduct daily calls, Monday-Friday to review staffing and determine if recruitment efforts are effective. The Removal Plan was validated onsite by the surveyor on 4/4/2024-4/5/2024 and included the following: 1. Surveyor validated through interviews with the facility's administrative and corporate staff they were knowledgeable about their responsibility to ensure sufficient staffing was maintained at the facility. a. The Administrative staff including the Administrator, DON, ADON, and staff scheduler were interviewed and stated daily meetings were being conducted and the staff scheduled were reviewed to ensure sufficient staffing. The interviewed staff stated when there were call ins by nursing staff including CNA's, other facility staff were asked to work and were offered incentives, in addition staffing agencies were called and were requested to assist. As a last resort if and if needed the DON, ADON, Wound Nurse, MDS nurse would assist with covering shifts to ensure safe staffing coverage. Through interviews with 7 CNA's, 5 LPN's, 2 RN's, the Wound Care Nurse, the MDS Coordinator, DON, and ADON revealed they had been educated and in-serviced on call ins and filling in shift as needed to maintain adequate staffing. 2. Review of the Recruitment Plan showed the facility had implemented the following to attain and retain staff: a. Job posting on line, verified through review of Indeed Job Recruitment. b. Social Media platforms c. A free cell phone to full time employees. d. Flyers were posted at the entrance of the facility regarding job openings. e. A Walk In Wednesday for job interviews at the facility. 3. Staffing was observed on both shifts 4/3/2024 to 4/5/2024. No short staffing was observed. Daily monitoring documentation of personnel on floor versus (vs) posted staffing matched. Punch report and staffing snap shots were reviewed and cross referenced against other falls investigated for Residents #3-#7 with no evidence of short staffing on the units and dates those falls occurred. Daily RN staffing was confirmed with observations and punch report checks during the survey period. Final walk through and staff/census counts conducted immediately before exit on 4/5/2024 showed no concerns. 4. Observations and interviews with the DON, ADON and Admin showed they had also underwent additional in service training conducted by the Corporate Compliance Consultant as reported in the AOC. Review of the QAPI sign in sheets and daily staffing calls showed those were completed as reported in the AOC. Medical director participation in the AOC/POC process was verified by her Nurse Practitioner onsite on 4/4/2024 and 4/5/2024. Prior to the exit conference (both participated and signed the QA sheets). 5. Daily observations of the scheduling calendar showed 4 agency personnel called off duty during the survey. All 4 open shifts were covered with other agency personnel or facility staff. The ADON covered a single 4-hour stint on 4/4/2024 until agency alternates could arrive due to staff tardiness due to a family emergency which was called to the ADON 8 hours in advance of the shift. This slot was eventually filled by an agency employee. Review and observation of the facility's AOC/Removal Plan, staffing schedules, staff postings, observation of staff and residents, daily staff meeting, and interviews showed the facility had implemented all corrective actions and the immediacy was removed onsite.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to follow their discharge policies and procedures and failed to meet the requirements for an appropriate discharge for 1 resident (#11) of 13 residents reviewed for discharge requirements. The facility's failure resulted in Resident #11, a cognitively impaired resident with multiple medical and psychological conditions and limited family/social support being discharged to her unsupervised home and placed Resident #11 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Resident #11 was hospitalized 12 days after discharge from the facility for altered mental status including hallucinations, worsening confusion, and inability to ambulate. Administrator #2 was notified of the Immediate Jeopardy on 1/12/2023 at 7:38 PM in the Administrator's office. The IJ began on 12/8/2022 and is ongoing. The findings include: Review of a facility policy, titled Transfer or Discharge Notice revised 12/2016 showed .Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge .The resident and/or representative (sponsor) will be notified in writing of the following information .The reason for the transfer or discharge .The effective date of the transfer or discharge .The reasons for the transfer or discharge will be documented in the resident's medical record . Review of facility's policy titled, Transfer or Discharge, Preparing a Resident for, revised on 12/2016, showed .Resident will be prepared for discharge. 1. When a resident is scheduled for transfer or discharge, Social Services Director will work with nursing services on the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family before the resident's discharge or transfer from the facility .Nursing services is responsible for .d. packing and collecting personal possessions (if the resident is not expected to return); e. assisting with transportation as applicable; f. Completing discharge note in the medical record; 4. Social Services (may have assistance from Business Office) is responsible for: a. Discharge planning b. Assisting with post discharge needs . Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Dementia with Behavioral Disturbance, and Major Depressive Disorder with Psychotic Symptoms. Review of Resident #11's History and Physical dated 5/24/2022 showed .77 yo [year old] diabetic .with dementia .endstage COPD .transfers for continued care and multi-disciplinary rehabilitation .ADVANCED CARE PLANNING .The patient has been deemed incompetent to make decisions on their behalf due to advanced dementia . Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 was rarely/never understood, had short- and long-term memory problems, and had moderately impaired cognitive skills for daily decision making. The resident exhibited daily physical and verbal behavioral symptoms, rejection of care, and wandering behaviors. Resident #11 required limited assistance of 1 staff member for transfers, walking in room and corridor, dressing, and personal hygiene. Resident #11 required extensive assistance of 1 staff member for toilet use and locomotion off the unit and supervision with set up assistance for eating. The resident had unsteady balance during transitions and walking and required mobility devices including walker and wheelchair. Resident #11 was always incontinent of urine and bowel. Resident #11 and Resident #11's family representative expected Resident #11 to remain in the facility. Review of Resident #11's Care Plan dated 6/7/2022 showed Resident #11 .has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia .At risk for falls related to weakness and need for assistance with ADL's [Activities of Daily Living], unsteady gait, confusion, medication .at risk for impaired nutrition r/t poor appetite . Review of Resident #11's Care Plan dated 6/17/2022, showed .resident has an ADL self-care performance deficit r/t dementia, decreased mobility .resident has a communication problem r/t dementia .resident has bowel incontinence .resident has bladder incontinence .resident is on pain medication therapy .resident has a mood problem .resident has a terminal prognosis - end stage COPD [Chronic Obstructive Pulmonary Disease] .oxygen therapy . Review of Resident #11's quarterly MDS assessment dated [DATE], showed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. The resident required limited assistance of 1 staff member for bed mobility and supervision of 1 staff member for transfers and walking in room and corridor. Resident #11 required extensive assistance of 1 staff member for dressing, toilet use and personal hygiene. Review of a Social Service Quarterly Note dated 11/25/2022 showed .resident [#11] is long term care with no current discharge plans .she is severely impaired for decision skills, scoring 7/15 [7 out of 15 - severe cognitive impairment] on BIMS . Review of a quarterly MDS assessment dated [DATE], showed Resident #11 had a BIMS score of 7 indicating severe cognitive impairment. Resident #11 required extensive assistance of 1 staff member for personal hygiene, toilet use, and dressing, limited assistance of 1 staff member for bed mobility, and supervision for transfers, eating, and ambulation. Resident #11 was always incontinent of bladder and bowel. The MDS for discharge planning showed there was no active discharge plan. Review of Resident #11's financial statement dated 12/1/2022 showed Resident #11 had a balance due of $3,435.00. Review of a Transaction Report dated 1/1/2020-1/31/2023 for Resident #11 showed 2 payments to the facility of $87.00 on 12/5/2022 and $600.00 on 12/8/2022. Continued review showed the facility had received monthly reimbursement of $235.53 per day from Hospice. Review of the Care Plan Conference Summary dated 12/1/2022, showed Resident #11's responsible family representative attended a care plan meeting with the Business Office Manager and the MDS Coordinator to discuss .home vs [versus] long term care . It was noted .Care plan meeting completed this day .[name of Responsible Family Representative] talked with [name of previous Business Office Manager] to clear up issues with payment He said he did not know payments were declined giving different payment info .before he left said he is responsible for 15 y/o [year old] son of [Resident #11's daughter] and that he has to work outside of the home. He would need a caregiver for some time [if Resident #11 was discharged back to the home]. Can revisit [possible discharge planning] when [Resident #11's daughter] gets out of jail . Review of a Psychiatric Progress note dated 12/5/2022 for Resident #11 showed .Hospice Patient .Dementia .FTT [failure to thrive] .seeing this resident today for treatment of dementia depression and insomnia .is awake she is alert she is oriented to herself and somewhat situation .she continues to have the delusion that she will soon be going home . Review of a standalone BIMS exam dated 12/5/2022, completed by the Social Worker and not in conjunction with any other assessments such as the MDS, showed a score of 10, indicating Resident #11 had moderate cognitive impairment. Review of a Nurse's note dated 12/7/2022 at 9:02 AM, showed .Resident's [#11] attention span is short. The resident is Disoriented/confused .Resident has impaired decision-making ability .makes repetitive statements . Review of a Skilled Nursing note dated 12/7/2022 at 9:39 AM, showed .Resident's [#11] attention span is short .is Disoriented/confused .has impaired decision-making ability .Unsteady Gait .BED MOBILITY .Limited assistance One person physical assist .TRANSFER: Limited assistance One person .EATING: Limited assistance One person .TOILET: Limited assistance One person . Review of a Master of Social Work (MSW) Hospice note dated 12/7/2022 at 7:29 PM, showed .MSW [Hospice MSW] VISITED WITH PT [patient - Resident #11] .FACILITY NURSE .REPORTED THAT PT IS ACTUALLY GOING HOME NEXT WEEK. [Hospice] MSW WAS UNAWARE OF PLAN .DURING PARTNERSHIP MEETING WITH [facility SW], SHE CONFIRMED THAT PT IS BEING DRIVEN TO HER HOME .BY [facility] STAFF .POLICE WILL BE NOTIFIED IF [Responsible Family Representative] WILL NOT LET HER IN (AS HOME BELONGS TO PT) .PT NO LONGER MEETS CRITERIA TO STAY IN FACILITY DESPITE FACT SHE IS ON HOSPICE .WILL NOTIFY MORRISTOWN OFFICE OF PT'S RETURN TO THEIR SERVICE AREA . Review of a Nurse Practitioner's (NP) note dated 12/8/2022 showed .discharging home under hospice with family today .Copy of discharge packet will be given at time of departure .Hospice aware of discharge today . Review of the Resident Discharge instruction form dated 12/8/2022, showed there was no discharge time or transportation arrangements documented. A handwritten note on the discharge documents showed .to [name of Responsible Family Representative] and/or Hospice Nurse . Review of the document showed it did not contain relevant resident specific information for discharge such as behaviors, ambulation, bladder, bowel, feeding, usual level of functioning, date, and time of transfer/discharge, transfer/discharged to, and any personal effects sent home with the resident. On the top of the document there was a handwritten note from the Nurse Practitioner that stated .Give to [Resident #11's Responsible Family Representative's first name] and/or Hospice Nurse . Review of a Hospice Master of Social Worker (MSW) note dated 12/9/2022 showed .CALLED [Resident #11's Responsible Family Representative] .PATIENT HAS BEEN IN A NURSING HOME IN [name of town] .HE REPORTS THAT THE NURSING HOME SENT HER [Resident #11] HOME AND THERE WAS NOBODY THERE . HE REPORTS THAT THE POLICE WAS CALLED .HE DISCUSSED HOW HE CANNOT TAKE CARE OF HER AND HER DAUGHTER IS IN JAIL. HE REPORTS IT'LL BE ANOTHER MONTH OR TWO MAYBE LONGER BEFORE SHE [daughter] GETS OUT THAT SHE [Resident #11] NEEDS TO GO TO THE FACILITY FOR LONG-TERM CARE .STATES THAT SHE [Resident #11] CANNOT STAY THERE BY HERSELF HE WORKS AND THERE'S NO WAY HE CAN HAVE SOMEBODY THERE 24/7 . Review of a Hospice Nurse note dated 12/9/2022 showed .[Hospice visit] REQUESTED BY CG [care giver] REGARDING TRANSFER FROM SNF [skilled nursing facility] .PT [Resident #11] WAS RELEASED FROM SNF WITH NO NEW SCRIPTS [prescriptions] OR ORDERS TO CONTINUE MEDICATIONS .SN [Skilled Nurse] NOTIFIED [pharmacy] .OF REQUIRED SCRIPTS .PATIENT .WITH SOME CONFUSION/FORGETFULNESS .UNABLE TO PROVIDE DAY OF WEEK AND CURRENT MONTH WITH OUT PROMPTING .PT IS FRAIL .CAN AMBULATE WITH USE OF WALKER AND REQUIRES STANDBY ASSIST .OCCASIONAL EPISODES OF INCONTINENCE .NO SUPPLIES IN THE HOME . Review of a Hospice Nursing note dated 12/20/2022 showed .CG NOTIFIED [Hospice Agency] ON CALL REGARDING CHANGE IN PATIENT'S [Resident #11] STATUS. HE REPORTED INCREASED ANXIETY AND CONFUSION .UPON ARRIVAL TO HOME .PATIENT LOOKED CONFUSED AND UNABLE TO ANSWER .PATIENT WAS CONFUSED . Review of the hospital Emergency Documentation dated 12/20/2022, showed Resident #11 was seen in the Emergency Department on 12/20/2022 for Altered Mental Status. It was noted .Associated Diagnoses: Acute on chronic alteration in mental status; Encounter for home safety review for injury prevention .Chief Complaint .Released from nursing home 1 week ago [12 days]. Hallucinating, and confused unable to ambulate to bathroom since [1:00 AM] today. Speech garbled thinks it is the 1800's .History of Present Illness .presents with altered mental status .disoriented and confused XXX[AGE] year old female presents to ER [emergency room] with her [Power of Attorney/Responsible Family Representative] who reports the patient has had worsening confusion .Patient was discharged from nursing home 8 days ago [12 days] after scoring higher on her mini mental exam .He has been attempting to care for her at home but is employed full-time, so the patient is often home alone. He is hoping to have the patient placed in a nursing home in this area .Disposition .admit: to Observation .Discussed with POA [Power of Attorney] that there is no obvious cause for patient's worsening confusion noted on medical imaging or laboratory study results .POA unable to care for patient at home. Will speak with hospitalist regarding admission due to unsafe discharge with hopes of possible SNF placement considering patient was discharged from SNF less than 30 days ago . Review of the hospital admission History and Physical Report dated 12/20/2022, showed .[Resident #11] Released from nursing home 1 week ago. Hallucinating, confused unable to ambulate to bathroom since 1 am today. Speech garbled thinks it is the 1800's .Surrogate Decision Maker: [Responsible Family Representative] .unfortunate [AGE] year old .female .past medical history of dementia, chronic UTIs who presents to the emergency room with increased confusion .discharged from the nursing home 8 days ago .she had been increasing wandering trying to go out the front door and to the door to the basement where there is stairs. He states that she has been more argumentative with him, and he states that she has stopped talking she just mumbles and plays with her hands .he felt that it possibly could be a urinary tract infection so he brought her to the emergency room today for further evaluation .I did have a lengthy discussion with him via phone, as the patient does have choices [CHOICES - State Medicaid Plan] .however they [CHOICES Medicaid] are understaffed and no one is available for assistance. He is looking at long term placement .In the emergency room, she did have laboratory and radiological studies. [NAME] count [white blood cells - high count indicative of an infection] is normal, H&H [hemoglobin and hematocrit] is stable, platelets are normal .Urinalysis is essentially negative .CT [computerized tomography] of brain which shows no acute intracranial findings .Assessment/Plan .Acute on chronic alteration in mental status .Encounter for home safety review for injury prevention .Consult case management for assistance with placement .Confusion .patient does have dementia .Adult failure to thrive . Review of the hospital Discharge summary dated [DATE], showed .Discharge Diagnosis .Adult failure to thrive .Anorexia .At risk for falls, COPD .Dementia .Encounter for home safety review for injury prevention .Hospital Course .admitted after being discharged from the nursing home 1 week prior to admission with hallucinations, confusion, unable to ambulate .admitted on [DATE] for acute on chronic alteration of mental status .Case management for assistance with patient SNF placement. Patient was accepted at .[another long-term care facility] for long-term care . During an interview on 1/9/2023 at 2:15 PM, the facility Social Worker (SW) stated Resident #11's Responsible Family Representative attended a care plan meeting on 12/1/2022 with the Business Office Manager and the MDS Coordinator. During the care plan meeting Resident #11's Responsible Family Representative stated that he would be unable to take Resident #11 home at that time because he was working outside the home and would need a caregiver for Resident #11. The SW stated Resident #11 verbalized that she wanted to go home (unknown what date the resident expressed this), and the SW completed a BIMS score for the resident on 12/5/2022 to determine if Resident #11 had the cognitive ability to make that decision. Resident #11 scored 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. The SW stated the facility determined that residents scoring greater than 8 on the BIMS, indicated the resident was able to make their own decisions and because Resident #11's BIMS score was 10, she was able to make the decision on her own if she wanted to go home. The SW stated she left a voicemail message with Resident #11's Responsible Family Representative on 12/6/2022 that Resident #11 would be discharged home on [DATE]. The SW stated she was unaware if Resident #11's Responsible Family Representative received the message and stated she never heard back from him. Resident #11 was discharged and taken home in the SW's private vehicle on 12/8/2022 by the SW and the Hospitality Aide. The SW stated upon arrival to Resident #11's home, there was no family members present and the SW called the police and fire department to gain entry to the home because Resident #11 did not have a key. The police arrived and stated they could not give access to the home. The SW stated Resident #11 entered the home through the back door and the SW went across the street to retrieve a neighbor (unable to provide any identifying information of the neighbor) who came to the resident's home to stay with the resident until family returned. The SW stated she left the patient discharge instructions and medications in .a drawer . The location of the drawer was unknown. She stated Resident #11's Responsible Family Representative left a message on 12/8/2022 for the SW and stated he was unable to locate the discharge instructions and medications. The SW was unable to provide documentation of Resident #11's discharge on [DATE]. The Social Worker stated .he was not paying her [Resident #11] bill .He [Responsible Family Representative] was living in her house .She had a right to go home . During an interview on 1/9/2023 at 2:40 PM, Certified Nurse Aide (CNA) #4 stated Resident #11 was a feisty little thing. The resident required supervision to ambulate, and assistance of 1 for toileting. The CNA stated her behavior would change from day to day. Some days she was confused and thought everyone was stealing her things. During an interview on 1/9/2023 at 3:30 PM, the Director of Nursing (DON) stated Resident #11 came into her office upset (unable to provide date this occurred) and stated she wanted a lawyer and wanted to go home. The DON confirmed she was aware Resident #11 had diagnoses of Dementia and End Stage Chronic Obstructive Pulmonary Disease. The DON stated she was unaware of the care plan meeting that occurred on 12/1/2022 with Resident #11's Responsible Family Representative, the Business Office Manager, and the MDS Coordinator where discharge planning was discussed. She stated she was unaware Resident #11 was sent home without family present. The DON confirmed there was no documentation of Resident #11's discharge in the medical record. The DON stated there was a corporate policy that stated if the resident had a BIMS score greater than 8, the resident was able to make their own decisions. The DON was unable to provide the policy as requested. The DON stated Resident #11's BIMS score was 10 and she wanted to go home and .it was her right to go home . During a telephone interview on 1/9/2023 at 7:18 PM, the Hospice Registered Nurse (RN) stated she was notified on 12/8/2022 at 4:30 PM, that Resident #11 was discharged home from the nursing home, and the Hospice RN was to make a visit to complete the admission. The Hospice RN arrived at Resident #11's home on [DATE] between 6:00 PM and 6:30 PM. Resident #11 was unaware of the month, date, and year and was unable to repeat the 3 words the Hospice RN asked her to remember. During a telephone interview on 1/9/2023 at 7:50 PM, Resident #11's Responsible Family Representative stated he was Resident #11's son-in law and the legal representative for Resident #11. He stated he attended a meeting at the facility approximately a week prior to 12/7/2022 with an Office Manager and a Case Manager. The Responsible Family Representative told the facility he lived in Resident #11's home with a minor child. Resident #11's daughter was incarcerated, and the Responsible Family Representative was the only possible care giver in the home, and he was working outside the home. He stated the plan was for Resident #11 to be discharged home when her daughter was out of jail, and they were able to get some care assistance from Medicaid Choices. The Responsible Family Representative stated he received a call from a nurse at Resident #11's hospice agency on 12/8/2022 asking if he had been notified that Resident #11 was being discharged from the nursing home that day. The Responsible Family Representative stated he was at work, no one was home, the doors were locked, and he was unable to get home until later in the afternoon. The Responsible Family Representative stated he had not received notice from the nursing home that the resident was being discharged home. The Responsible Family Representative stated he had made a payment for Resident #11's care on the day of the care plan meeting. During an interview on 1/10/2023 at 7:30 AM, the Wound Care Nurse stated Resident #11 was a sassy little lady. She was on hospice and had dementia with periods of confusion. She stated the resident was incontinent of bowel and bladder at times, required oxygen continuously, and required assistance with ADLs and supervision to ambulate. During an interview on 1/10/2023 at 7:50 AM, CNA #9 stated Resident #11 was a small lady who required oxygen. He stated the resident had dementia with periods of confusion. The CNA stated there were times the resident would be talking to the wall, thought she was in her home, and looking for her parked car. He stated the resident required supervision with ambulation and assistance of 1 staff for ADLs and toileting. During an interview on 1/10/2023 at 8:15 AM, Hospitality Aide #1 stated she accompanied the Social Worker to take Resident #11 home on [DATE] in the Social Worker's private vehicle. He stated they arrived at Resident #11's home and the resident did not have a key. He stated the front door was locked, no one answered the door and the police showed up. He stated the police stated they could not gain entry into the house and the police left. He stated he entered an unlocked basement door and Resident #11 told him to go in and unlock the front door, which he did. He stated the resident entered the house and sat on the couch. The Hospitality Aide stated a neighbor was present with the resident when they left. He was not able to provide any information about the neighbor the resident was left with on 12/8/2022. During an interview on 1/10/2023 at 9:55 AM, the MDS Coordinator stated she attended the care plan meeting on 12/1/2022 with Resident #11's Responsible Family Representative and the Business Office Manager (no longer employed at the nursing facility). She stated the Social Worker was unable to attend this meeting. The MDS coordinator stated Resident #11's Responsible Family Representative stated he was aware Resident #11 wanted to go home but he was unable to care for Resident #11 at that time because the resident's daughter was in jail, and he was working outside the home. The Responsible Family Representative stated he wanted to wait until Resident #11's daughter returned home before proceeding with Resident #11 returning home. The MDS Coordinator confirmed she relayed the care plan meeting information to the Social Worker. During an interview on 1/10/2023 at 3:30 PM, the NP stated she was notified when residents were being discharged . The NP stated she was unaware that Resident #11's family was not notified that the resident was discharging from the facility on 12/8/2022. The SW told the NP Resident #11's family had agreed to take the resident home. The NP stated if she had been aware that Resident #11's Responsible Family Representative had not agreed to the discharge, she would not have approved Resident #11's discharge. During an interview on 1/10/2023 at 4:00 PM, Administrator #1 stated in this facility, if a resident had a BIMS score greater than 8, the resident was able to make their own decisions. He stated the Social Worker coordinated the discharge and .gets with the NP . The Administrator stated he had not been involved in the discharges. He stated Resident #11 wanted to go home and she could make her own decisions based on Resident #11's last BIMS score (dated 12/5/2022). The Administrator stated he was unsure what Resident #11 was capable of doing for herself. He stated the Social Worker called him after the resident had been dropped off at her residence. He stated he was unaware Resident #11's family was not present at the home at the time of the resident's discharge. Administrator #1 confirmed it was the Administrator's responsibility to ensure all residents at the facility had a safe transfer or discharge. Administrator #1 stated Resident #11's discharge .wasn't a direct billing problem .that's [discharge] what she [Resident #11] wanted and she can make her own decisions . Administrator #1 stated Resident #11 was not discharged due to non-payment. During an interview on 1/10/2023 at 4:50 PM, the Medical Director confirmed Resident #11 had substantial Dementia, had poor problem-solving skills and poor insight. The resident was not capable or competent to be discharged without a caregiver. The Medical Director stated a BIMS score greater than 8 alone is a .single slice of time . and not enough information and evidence to base a decision of resident competence. The Medical Director confirmed Resident #11's discharge from the SNF to the resident's home was not a safe and orderly discharge. During a telephone interview on 1/11/2023 at 8:30 AM, Police Officer #1 stated he was called to Resident #11's home on [DATE]. He stated on arrival, there was a female and male employee from a nursing home with Resident #11 in the back seat. He stated the employees told him the facility .hadn't received a payment since May . and they requested the officer assist them in gaining entry to the home. The Officer stated he instructed the nursing home employees that he could not gain entry into the resident's home without just cause. The female nursing home staff (Social Worker) asked the police officer if the officer could take the resident with him. The Officer stated to the SW he could not take the resident. The Officer stated when he left, the 2 nursing home employees were outside of Resident #11's residence. The Officer stated the same day, an hour or 2 later, he received a call from Resident #11's Responsible Family Representative who stated there was damage done to the basement door by facility staff and the resident was left at the home unattended, and he had not been notified. The Responsible Family Representative declined to press charges against the facility for the damaged basement door. During an interview on 1/11/2023 at 9:50 AM, the Regional Clinical Regulatory Compliance Risk Manager confirmed Resident #11 was sent home without notification to the resident's Responsible Family Representative. She stated it was not normal procedure to discharge residents in staff private vehicles. She stated this was not a safe discharge for Resident #11 and the facility's policy and procedure for discharge was not followed. During an interview on 1/11/2023 at 3:52 PM, the Director of Nursing (DON) stated Resident #11 came to her office .probably a little before Thanksgiving . and stated she knew her rights and wanted to go home. The Social Worker did a BIMS assessment on 12/5/2022 to determine if Resident #11 was safe to go home. Resident #11 scored a 10 on the BIMS assessment on 12/5/2022 and that indicated she was able to make her own decision to go home. The DON stated she felt Resident #11 was safe to go home because she was told by the Social Worker that Resident #11's Responsible Family Representative was going to be the resident's caregiver. The DON confirmed Resident #11 needed a caregiver in the home. During a telephone interview on 1/12/2023 at 8:42 AM, Resident #11's Responsible Family Representative stated he received a call from his minor stepson on 12/8/2022 that someone was trying to get in the house. He stated he instructed him to keep the doors locked and keep out of sight and call the police. He stated when he returned to the residence on 12/8/2022 he found Resident #11 at the home unsupervised. He stated he notified hospice of Resident #11's discharge and called the hospice agency to request a nursing visit. The Responsible Family Representative and the hospice nurse were unable to locate the resident's discharge instructions and medications. He stated he called the facility to inquire about the discharge instructions and medications and did not hear back until the following day, 12/9/2022. He stated the resident had a decline in her condition, stopped eating and drinking, was more confused, and was wandering around the house looking out the front door. Resident #11 was later taken to the emergency department at the hospital and was admitted to the hospital until she was transferred to a different nursing home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide written notification of a discharge to a resident's representative for 1 resident (#11) of 13 residents reviewed for transfer/discharge requirements. The facility's failure resulted in Resident #11, a cognitively impaired resident with multiple medical and psychological conditions and limited family/social support, being discharged to an unsupervised home without notice to a care giver and placed Resident #11 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Resident #11 was hospitalized 12 days after discharge from the facility for altered mental status including hallucinations, worsening confusion, and inability to ambulate. Administrator #2 was notified of the Immediate Jeopardy on 1/12/2023 at 7:38 PM, in the Administrator's office. The IJ began on 12/8/2022 and is ongoing. The findings include: Review of a facility policy, titled Transfer or Discharge Notice revised 12/2016 showed .Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge .The resident and/or representative (sponsor) will be notified in writing of the following information .The reason for the transfer or discharge .The effective date of the transfer or discharge .The location to which the resident is being transferred or discharged .A statement of the resident's rights to appeal the transfer or discharge .The facility bed-hold policy .The name, address, and telephone number of the Office of the State Long-term Care Ombudsman .The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities .The name, address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices .The reasons for the transfer or discharge will be documented in the resident's medical record . Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Dementia with Behavioral Disturbance, and Major Depressive Disorder with Psychotic Symptoms. Review of Resident #11's History and Physical dated 5/24/2022 showed .77 yo [year old] diabetic .with dementia .endstage COPD .transfers for continued care and multi-disciplinary rehabilitation .ADVANCED CARE PLANNING .The patient has been deemed incompetent to make decisions on their behalf due to advanced dementia . Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 was rarely/never understood, had short- and long-term memory problems, and had moderately impaired cognitive skills for daily decision making. The resident exhibited daily physical and verbal behavioral symptoms, rejection of care, and wandering behaviors. Resident #11 required limited assistance of 1 staff member for transfers, walking in room and corridor, dressing, and personal hygiene. Resident #11 required extensive assistance of 1 staff member for toilet use and locomotion off the unit and supervision with set up assistance for eating. The resident had unsteady balance during transitions and walking and required mobility devices including walker and wheelchair. Resident #11 was always incontinent of urine and bowel. Resident #11 and Resident #11's family representative expected Resident #11 to remain in the facility. Review of Resident #11's Care Plan dated 6/7/2022 showed Resident #11 .has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia .At risk for falls related to weakness and need for assistance with ADL's [Activities of Daily Living], unsteady gait, confusion, medication .at risk for impaired nutrition r/t poor appetite . Review of Resident #11's Care Plan dated 6/17/2022, showed .resident has an ADL self-care performance deficit r/t dementia, decreased mobility .resident has a communication problem r/t dementia .resident has bowel incontinence .resident has bladder incontinence .resident is on pain medication therapy .resident has a mood problem .resident has a terminal prognosis - end stage COPD .oxygen therapy . Review of Resident #11's quarterly MDS assessment dated [DATE], showed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. The resident required limited assistance of 1 staff member for bed mobility and supervision of 1 staff member for transfers and walking in room and corridor. Resident #11 required extensive assistance of 1 staff member for dressing, toilet use and personal hygiene. Review of a Social Service Quarterly Note dated 11/25/2022 showed .resident [#11] is long term care with no current discharge plans .she is severely impaired for decision skills, scoring 7/15 [7 out of 15 which indicated severe cognitive impairment] on BIMS . Review of a quarterly MDS assessment dated [DATE], showed Resident #11 had a BIMS of 7, indicating severe cognitive impairment. Resident #11 required extensive assistance of 1 staff member for personal hygiene, toilet use, and dressing, limited assistance of 1 staff member for bed mobility, and supervision for transfers, eating, and ambulation. Resident #11 was always incontinent of bladder and bowel. The MDS for discharge planning showed there was no active discharge plan. Review of the Care Plan Conference Summary dated 12/1/2022, showed Resident #11's responsible family representative attended a care plan meeting with the Business Office Manager and the MDS Coordinator to discuss .home vs [versus] long term care . It was noted .Care plan meeting completed this day .[Responsible Family Representative] .said he is responsible for 15 y/o [year old] son of [Resident #11's daughter] and that he has to work outside of the home. He would need a caregiver for some time [if the resident was discharged home]. Can revisit [possible discharge planning] when [Resident #11's daughter] gets out of jail . Review of a Psychiatric Progress note dated 12/5/2022 for Resident #11 showed .Hospice Patient .Dementia .FTT [failure to thrive] .seeing this resident today for treatment of dementia depression and insomnia .is awake she is alert she is oriented to herself and somewhat situation . Review of a standalone BIMS exam dated 12/5/2022, completed by the Social Worker and not in conjunction with any other assessments such as the MDS, showed a score of 10, indicating Resident #11 had moderate cognitive impairment. Review of a skilled nursing note dated 12/7/2022 at 9:39 AM, showed .Residents' [#11] attention span is short .is Disoriented/confused .has impaired decision-making ability .Unsteady Gait .BED MOBILITY .Limited assistance One person physical assist .TRANSFER: Limited assistance One person .EATING: Limited assistance One person .TOILET: Limited assistance One person . Review of a Master of Social Work (MSW) Hospice note dated 12/7/2022 at 7:29 PM, showed the Hospice MSW was informed by the facility SW that Resident #11 was going home the next week. The Hospice MSW was unaware of any discharge planning. Review of a Nurse Practitioner (NP) order dated 12/8/2022, showed an order to discharge Resident #11 home with hospice. Review of a NP note dated 12/8/2022, showed .[Resident #11] discharging home under hospice with family today .Hospice aware of discharge today . Review of Resident #11's medical record revealed no documentation a discharge notice was provided to the Responsible Family Representative/care giver prior to discharge. Review of a Hospice Master of Social Worker (MSW) note dated 12/9/2022, showed .CALLED [Responsible Family Representative] .PATIENT [Resident #11] HAS BEEN IN A NURSING HOME IN [name of town] .HE REPORTS THAT THE NURSING HOME SENT HER HOME AND THERE WAS NOBODY THERE AND THEY BROKE IN THE DOOR HE REPORTS THAT THE POLICE WAS CALLED .HE DISCUSSED HOW HE CANNOT TAKE CARE OF HER [Resident #11] AND HER DAUGHTER IS IN JAIL. HE REPORTS IT'LL BE ANOTHER MONTH OR TWO MAYBE LONGER BEFORE SHE [daughter] GETS OUT THAT SHE [Resident #11] NEEDS TO GO TO THE FACILITY FOR LONG-TERM CARE .STATES THAT SHE CANNOT STAY THERE BY HERSELF HE WORKS AND THERE'S NO WAY HE CAN HAVE SOMEBODY THERE 24/7 . Review of the hospital Emergency Documentation dated 12/20/2022, showed Resident #11 presented to the Emergency Department with her Responsible Family Representative for worsening Altered Mental Status and concerns with home safety. Resident #11 had been hallucinating, had confusion, and had been unable to ambulate to the bathroom. Her speech was garbled, and she thought it was the 1800's. The Responsible Family Representative stated he had been attempting to care for Resident #11 at home but was employed full-time, so she was often home alone. He hoped to have Resident #11 placed in a nursing home as he was unable to provide safe care for her at home. Review of the hospital admission History and Physical Report dated 12/20/2022, showed Resident #11 had a past medical history of dementia and presented to the emergency department with increased confusion, mumbled speech, and playing with her hands. Resident #11 had recently been discharged from a nursing facility and since then she had increased wandering, with exit seeking behaviors. The Responsible Family Representative was seeking long term placement. Resident #11 was admitted to the hospital for changes in mental status and concerns for home safety. Case management was consulted for assistance with nursing home placement. Resident #11 was diagnosed with confusion, dementia, and adult failure to thrive. Review of the hospital Discharge Summary for Resident #11 dated 1/5/2023, showed .Discharge Diagnosis .Adult failure to thrive .Anorexia .At risk for falls, COPD .Dementia .Encounter for home safety review for injury prevention . During an interview on 1/9/2023 at 2:15 PM, the Social Worker (SW) stated she left a voicemail message with Resident #11's Responsible Family Representative on 12/6/2022 that Resident #11 would be discharged home on [DATE]. The SW stated she was unaware if Resident #11's Responsible Family Representative received the message and stated she never heard back from him. The SW confirmed Resident #11's Responsible Family Representative was not sent a written notice of the resident's discharge and there was no documentation of the Responsible Family Representative notification on 12/6/2022. Resident #11 was discharged home in the SW's private vehicle on 12/8/2022 by the SW and the Hospitality Aide. Upon arrival to Resident #11's home, there were no family members present and the SW called the police and fire department to gain entry to the home because Resident #11 did not have a key. The police arrived and stated they could not give access to the home. The SW stated entrance was gained to the home through the back door and the SW went across the street to retrieve a neighbor who came to the resident's home to stay with the resident until family returned. The SW was unable to provide documentation of Resident #11's discharge on [DATE] and unable to provide any identifying information for the neighbor. During an interview on 1/9/2023 at 3:30 PM, the Director of Nursing (DON) stated Resident #11 came into her office upset (unable to provide date of occurrence) and stated she wanted a lawyer and wanted to go home. The DON was aware that Resident #11 had diagnoses of Dementia and End Stage Chronic Obstructive Pulmonary Disease. The DON stated she was unaware of the care plan meeting that occurred on 12/1/2022 with Resident #11's Responsible Family Representative, the Business Office Manager, and the MDS Coordinator where discharge planning was discussed. The DON confirmed the Responsible Family Representative was to be notified prior to discharge and stated she .assumed . the SW notified him. During a telephone interview on 1/9/2023 at 7:18 PM, the Hospice Registered Nursed (RN) stated she was notified on 12/8/2022 at 4:30 PM, that Resident #11 was discharged home from the nursing home, and the Hospice RN was to make a visit to complete the admission. The Hospice RN arrived at Resident #11's home on [DATE] between 6:00 PM and 6:30 PM. Resident #11's Responsible Family Representative stated he had not been made aware Resident #11 was being discharged from the facility on 12/8/2022. During a telephone interview on 1/9/2023 at 7:50 PM, Resident #11's Responsible Family Representative stated he was Resident #11's son-in law and the legal representative for Resident #11. He stated he attended a meeting at the facility approximately a week prior to 12/7/2022. He stated the plan was for Resident #11 to be discharged home when her daughter was out of jail, and they were able to get some care assistance from Medicaid Choices. The Responsible Family Representative stated he received a call from a nurse at Resident #11's hospice agency on 12/8/2022 asking if he had been notified that Resident #11 was being discharged from the nursing home that day. The Responsible Family Representative stated he had not received notice from the nursing home that the resident was being discharged home. During an interview on 1/10/2023 at 3:30 PM, the NP stated she was notified when residents were being discharged . The NP stated she was unaware that Resident #11's family was not notified that the resident was discharging from the facility on 12/8/2022. The SW told the NP Resident #11's family had agreed to take the resident home. The NP stated if she had been aware that Resident #11's Responsible Family Representative had not agreed to the discharge, she would not have approved Resident #11's discharge. During an interview on 1/10/2023 at 4:50 PM, the Medical Director stated Resident #11 had substantial Dementia, poor problem-solving skills, and poor insight. The resident was not capable or competent to be discharged without a caregiver. During an interview on 1/11/2023 at 9:50 AM, the Regional Clinical Regulatory Compliance Risk Manager confirmed Resident #11 was discharged home without notification to the family or family representative. The Regional Clinical Regulatory Compliance Risk Manager stated residents, or the resident representative was to be notified of discharge prior to the discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, and interview the facility failed to implement an effective discharge planning process to ensure a safe and effective discharge for 3 residents (Residents #11, #25, and #32) of 13 residents reviewed for transfer/discharge requirements which resulted in Resident #11 being hospitalized 12 days after discharge from the facility for altered mental status including hallucinations, worsening confusion, and inability to ambulate; Resident #25 being hospitalized 4 days after discharge from the facility for Purulent Cellulitis, Infection of Pressure Ulcer, and Osteomyelitis, and Resident #32 being discharged home without home health services arranged. The facility's failure resulted in Resident #11, a cognitively impaired resident with multiple medical and psychological conditions and limited family/social support being discharged to an unsupervised home without notice or immediate discharge instructions and Resident #25, who had a Left Below Knee Amputation, Cellulitis of Left Lower Limb (Amputated Stump), Pressure Ulcer of Stump, and Type 2 Diabetes being discharged home without adequate dressing supplies, wound care instructions, a home health wound care provider or therapy arranged. The facility's failure placed Resident #11 and Resident #25 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Administrator #2 was notified of the Immediate Jeopardy on 1/12/2023 at 7:38 PM in the Administrator's office. The IJ was effective on 12/8/2022 and is ongoing. The findings include: Review of the facility's policy titled, Transfer or Discharge Notice, revised on 12/2016 showed .The resident and/or representative (sponsor) will be notified in writing of the following information .The reason for the .discharge .The effective date of the .discharge .The location to which the resident is being .discharged .The reasons for the transfer or discharge will be documented in the resident's medical record . Review of the facility policy, titled Discharge Summary revised 11/8/2022 showed .The discharge summary provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge .A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another .A discharge summary may help reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident's care .In case of discharge to a non-institutional setting such as the resident's home, provision of a discharge summary, with the resident's consent, to the resident's community-based physicians/practitioners allows the resident to receive continuous and coordinated, person centered care .Content of the Discharge Summary Recapitulation of Resident's Stay [concise summary of the resident's stay] .Recapitulation of the resident's stay describes the resident's course of treatment while residing in the facility .The recapitulation includes, but is not limited to, diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultant results, including any pending lab results . Review of facility policy, Transfer or Discharge, Preparing a Resident for revised date 12/2016, showed Resident will be prepared for discharge. 1. When a resident is scheduled for transfer or discharge, Social Services Director will work with the nursing services on the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. The plan will be reviewed with the resident, and/or his or her family before the resident's discharge or transfer from the facility. 3. Nursing services is responsible for: a. obtaining orders for discharge or transfer; b. preparing the discharge summary; c. preparing the medications to be discharged with the resident (as permitted by law); d. packing and collecting personal possessions (if the resident is not expected to return); e. assisting with transportation as applicable; f. completing discharge note in the medical record; 4. Social Services (may have assistance from Business Office) is responsible for: a. Discharge planning b. assisting with post discharge needs such as arranging for equipment needed after discharge, assisting with Home Health is ordered . Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Dementia with Behavioral Disturbance, and Major Depressive Disorder with Psychotic Symptoms. Review of Resident #11's History and Physical dated 5/24/2022 showed 77 yo [year old] diabetic .with dementia .ADVANCED CARE PLANNING .The patient has been deemed incompetent to make decisions on their behalf due to advanced dementia . Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 was rarely/never understood, had short- and long-term memory problems, and had moderately impaired cognitive skills for daily decision making. The resident exhibited daily physical and verbal behavioral symptoms, rejection of care, and wandering behaviors. Resident #11 required limited assistance of 1 staff member for transfers, walking in room and corridor, dressing, and personal hygiene. Resident #11 required extensive assistance of 1 staff member for toilet use and locomotion off the unit and supervision with set up assistance for eating. The resident had unsteady balance during transitions and walking and required mobility devices including walker and wheelchair. Resident #11 was always incontinent of urine and bowel. Resident #11 and Resident #11's family representative expected Resident #11 to remain in the facility. Review of Resident #11's Care Plan dated 6/7/2022 showed Resident #11 .has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia . The care plan did not reflect a discharge plan was in place for Resident #11. Review of Resident # 11's care plan conference summary dated 8/25/2022 showed DON [Director of Nursing] spoke [Responsible Family Representative] today regarding resident's discharge vs [versus] LTC [long term care] .he agreeable to keep in house and keep comfortable for now .agreed to set some goals for her to achieve before he could take her home . Review of a Social Service Quarterly Note dated 11/25/2022, showed .resident [#11] is long term care with no current discharge plans .she is severely impaired for decision skills, scoring 7/15 [score of 7 out of 15 indicates severe cognitive impairment] on BIMS [Brief Interview for Mental Status] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 had a BIMS score of 7 indicating severe cognitive impairment. Resident #11 required extensive assistance of 2 staff members for personal hygiene and extensive assistance of 1 staff member for dressing and toilet use. The resident required limited assistance of 1 staff member for bed mobility and supervision of 1 staff member for transfers, eating, and ambulation. Resident #11 was always incontinent of bladder and bowel. Continued review of the MDS for the Discharge Plan showed there was no active discharge planning. Review of the Care Plan Conference Summary dated 12/1/2022, showed Resident #11's responsible family representative attended a care plan meeting to discuss .home vs [versus] long term care . It was noted .Care plan meeting completed this day .[Responsible Family Representative] .said he is responsible for 15 y/o [year old] son of [Resident #11's daughter] and that he has to work outside of the home. He would need a caregiver for some time [if Resident #11 discharged home]. Can revisit [discharge planning] when [Resident #11's daughter] gets out of jail . Review of the Care Plan conference summary dated 12/1/2022 showed the Responsible Family Representative wasn't able to provide the care needed at home for Resident #11. The facility documentation of the care plan meeting on 12/1/2022 did not reflect there any discharge plans for a specific target date. Review of a Psychiatric Progress note for Resident #11 dated 12/5/2022 showed .Hospice Patient .Dementia .FTT [failure to thrive] seeing this resident today for treatment of dementia depression and insomnia .is awake she is alert she is oriented to herself and somewhat situation .she continues to have the delusion that she will soon be going home . Review of a Skilled Nursing note for Resident #11 dated 12/7/2022 at 9:39 AM, showed .Residents' attention span is short .is Disoriented/confused .has impaired decision-making ability .Unsteady Gait . Review of a Nurse Practitioner's (NP) note dated 12/8/2022 showed .discharging home under hospice with family today .Discussed all discharge instructions and medications with [Resident #11] and family member at bedside. Voice no questions and have no concerns at this time. Copy of discharge packet will be given at time of departure .Hospice aware of discharge today . (Interview with NP on 1/10/2023 below in the narrative shows the NP stated that this documentation was made in error, and she had not educated the responsible family representative on discharge instructions or medications). Medical record review showed this was the first documentation of a planned discharge from the facility for Resident #11. Review of the Resident Discharge instruction form dated 12/8/2022, showed there was no discharge time or transportation arrangements documented. A handwritten note on the discharge document showed .to [name of Responsible Family Representative] and/or Hospice Nurse . Review of the document showed it did not contain relevant resident specific information for discharge such as behaviors, ambulation, bladder, bowel, feeding, usual level of functioning, date, and time of transfer/discharge, transfer/discharged to, and any personal effects sent home with the resident. On the top of the document there was a handwritten note from the Nurse Practitioner that stated .Give to [Resident #11's Responsible Family Representative] and/or Hospice Nurse . Continued review showed a list of the resident's medications while at the facility, but it did not include any instructions to continue or discontinue the medications or the date and time the medications were last administered. Review of a Master of Social Work (MSW) Hospice note dated 12/7/2022 at 7:29 PM, showed .[Hospice] MSW VISITED WITH PT [patient - Resident #11] .FACILITY NURSE .REPORTED THAT PT [Resident #11] IS ACTUALLY GOING HOME NEXT WEEK. [Hospice] MSW WAS UNAWARE OF PLAN .DURING PARTNERSHIP MEETING WITH [facility Social Worker], SHE CONFIRMED THAT PT IS BEING DRIVEN TO HER HOME .BY [facility] STAFF .POLICE WILL BE NOTIFIED IF [Responsible Family Representative] WILL NOT LET HER IN (AS HOME BELONGS TO PT) .PT NO LONGER MEETS CRITERIA TO STAY IN FACILITY DESPITE FACT SHE IS ON HOSPICE .WILL NOTIFY MORRISTOWN OFFICE OF PT'S RETURN TO THEIR SERVICE AREA . Review of a Hospice Master of Social Worker (MSW) note dated 12/9/2022, showed .CALLED [Resident #11's Responsible Family Representative] .PATIENT [Resident #11] HAS BEEN IN A NURSING HOME IN [name of town] .HE REPORTS THAT THE NURSING HOME SENT HER [Resident #11] HOME AND THERE WAS NOBODY THERE .THE POLICE WAS CALLED .HE DISCUSSED HOW HE CANNOT TAKE CARE OF HER AND HER DAUGHTER IS IN JAIL. HE REPORTS IT'LL BE ANOTHER MONTH OR TWO MAYBE LONGER BEFORE SHE [Resident #11's daughter] GETS OUT THAT SHE [Resident #11] NEEDS TO GO TO THE FACILITY FOR LONG-TERM CARE .STATES THAT SHE CANNOT STAY THERE BY HERSELF HE WORKS AND THERE'S NO WAY HE CAN HAVE SOMEBODY THERE 24/7 . Review of a Hospice Nurse note dated 12/9/2022 showed .REQUESTED BY CG [Care Giver] REGARDING TRANSFER FROM SNF [skilled nursing facility] .PT [Resident #11] WAS RELEASED FROM SNF [Skilled Nursing Facility] WITH NO NEW SCRIPTS [prescriptions] OR ORDERS TO CONTINUE MEDICATIONS .SN [Skilled Nurse] NOTIFIED [pharmacy] .OF REQUIRED SCRIPTS. NEW ORDER OBTAINED FOR LORTAB [narcotic pain medication] .Q6H [every 6 hours] .PATIENT A/O X2 [alert and oriented times 2 - to person and place] WITH SOME CONFUSION/FORGETFULNESS .UNABLE TO PROVIDE DAY OF WEEK AND CURRENT MONTH WITH OUT PROMPTING .PT IS FRAIL, 02 [oxygen] DEPENDENT .CAN AMBULATE WITH USE OF WALKER AND REQUIRES STANDBY ASSIST .OCCASIONAL EPISODES OF INCONTINENCE .NO SUPPLIES IN THE HOME . Review of a Hospice Nursing note dated 12/20/2022 showed .CG NOTIFIED ON CALL [Hospice Agency Staff] REGARDING CHANGE IN PATIENT'S [Resident #11] STATUS. HE REPORTED INCREASED ANXIETY AND CONFUSION .UPON ARRIVAL TO HOME .PATIENT LOOKED CONFUSED AND UNABLE TO ANSWER .PATIENT WAS CONFUSED INABLE TO FOLLOW COMMAND .SUSPECTED UTI [urinary tract infection] .ORDERED MACROBID [medication used to treat infection] . Review of the hospital Emergency documentation dated 12/20/2022, showed .[Resident #11] admitted for Altered Mental Status, Acute on Chronic alteration in mental status .Encounter for home safety review for injury prevention .Pt [patient] was discharged from nursing home 8 days ago [12 days] .POA [Power of Attorney] unable to care for her at home he is employed full-time, so patient is often home alone . Resident #11 had been hallucinating, had confusion, and had been unable to ambulate to the bathroom. Her speech was garbled, and she thought it was the 1800's. Review of hospital admission History and Physical Report dated 12/20/2022, showed [Resident #11] Released from nursing home 1 week ago [12 days]. Hallucinating confused unable to ambulate to bathroom since 1 am today. Speech garbled thinks it is late 1800's . she had been increasing wandering trying to get out front door .door to the basement where there is stairs .Assessment/Plan .Acute on chronic alteration in mental status .Encounter for home safety review for injury prevention .Case Management for assistance with placement .Confusion .Chronic and stable, patient does have dementia .Adult Failure to Thrive . Resident #11 was admitted to the hospital for changes in mental status and concerns for home safety. Case management was consulted for assistance with nursing home placement. Review of the hospital Discharge summary dated [DATE], showed .Discharge Diagnosis .Adult failure to thrive .Anorexia .At risk for falls, COPD .Dementia .Encounter for home safety review for injury prevention .Hypothyroidism .Type 2 diabetes mellitus .Hospital Course .admitted after being discharged from the nursing home 1 week prior to admission with hallucinations, confusion, unable to ambulate .admitted on [DATE] [12/20/2022] for acute on chronic alteration of mental status .Case management for assistance with patient SNF [skilled nursing facility] placement. Patient was accepted at [another long-term care facility] for long-term care . During an interview on 1/11/2023 at 5:28 PM, the MDS Coordinator confirmed the discharge planning started on admission. She stated MDS was responsible for care planning based on the resident's goals, preferences, and plans for discharge. The MDS Coordinator stated she and Social Services were responsible for the discharge planning for residents. The MDS Coordinator confirmed Resident #11 had no discharge care plan. During an interview on 1/9/2023 at 2:15 PM, the Social Worker (SW) stated she was responsible for assisting residents with home health referrals, medical equipment, notifying hospice and family, and setting up transfer arrangements for residents at discharge. Resident #11's Responsible Family Representative attended a care plan meeting on 12/1/2022 with the Business Office Manager and the MDS Coordinator. During the care plan meeting, Resident #11's Responsible Family Representative stated that he would be unable to take Resident #11 home at that time because he was working outside the home and would need a caregiver for Resident #11. The SW stated Resident #11 verbalized that she wanted to go home (on an unknown date), and the SW completed a BIMS score for the resident on 12/5/2022. Resident #11 scored 10 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. The SW stated at this facility, if a resident's BIMS score was greater than 8, that indicated the resident was able to make their own decisions, and because Resident #11's BIMS score was 10, she was able to make the decision on her own if she wanted to go home. The SW left a voicemail message with Resident #11's Responsible Family Representative on 12/6/2022 that Resident #11 would be discharged home on [DATE]. The SW stated she was unaware if Resident #11's Responsible Family Representative received the message and stated she never heard back from him. The SW confirmed there was no documentation of the Responsible Family Representative notification. Resident #11 was discharged home in the SW's private vehicle on 12/8/2022 by the SW and the Hospitality Aide. Upon arrival to Resident #11's home, there were no family members present and the SW called the police and fire department to gain entry to the home because Resident #11 did not have a key. The police arrived and stated they could not give access to the home. The SW stated Resident #11 entered the home through the back door and the SW went across the street to retrieve a neighbor (unable to provide any identifying information about the neighbor) who came to the resident's home to stay with the resident until family returned. The SW left the patient discharge instructions and medications in a .drawer . Resident #11's Responsible Family Representative left a message for the SW on 12/8/2022 and stated he was unable to locate the discharge instructions and medications. The SW stated she returned the call to the Responsible Family Representative the next day on 12/9/2022 and the family member was able to find the discharge documents and medications (unable to provide a timeframe as there was no facility documentation regarding Resident #11's discharge). The SW was unable to provide further documentation of Resident #11's discharge on [DATE]. The SW stated it was decided between the DON, Administrator and Resident #11 that she had the right to go home since she had scored a 10 on the BIMS score. During an interview on 1/9/2023 at 3:30 PM, the Director of Nursing (DON) stated Resident #11 came into her office upset (unable to provide date of occurrence) and stated she wanted a lawyer and wanted to go home. The DON was aware that Resident #11 had diagnoses of Dementia and End Stage Chronic Obstructive Pulmonary Disease. The DON stated she was unaware of the care plan meeting that occurred on 12/1/2022 with Resident #11's Responsible Family Representative, the Business Office Manager, and the MDS Coordinator where discharge planning was discussed. The DON confirmed the Responsible Family Representative was to be notified prior to discharge and stated she .assumed . the SW notified him. She stated she was unaware Resident #11 was sent home without family present. The DON confirmed there was incomplete documentation of Resident #11's discharge in the medical record. The DON stated there was a corporate policy that stated if the resident had a BIMS score greater than 8, the resident was able to make their own decisions. The DON was unable to provide the policy as requested related to BIMS scores and resident decision making. The DON stated Resident #11's BIMS score was 10 and she wanted to go home and .it was her right to go home . The DON stated .I've never been very big in the discharge process as a DON . The DON stated to her knowledge no other care plan discharge meeting had been completed other that the care plan meeting on 12/1/2022. The DON stated a safe resident discharge included notification and communication with family, and coordination of home health and/or hospice services. During an interview on 1/10/2023 at 9:55 AM, the MDS Coordinator stated she attended the care plan meeting on 12/1/2022 with Resident #11's Responsible Family Representative and the Business Office Manager (who was no longer employed). She stated the Social Worker was unable to attend this meeting. The MDS coordinator stated Resident #11's Responsible Family Representative stated he was aware Resident #11 wanted to go home, but he was unable to care for Resident #11 at that time because the resident's daughter was in jail, and he was working outside the home. He stated he wanted to wait until the daughter returned to the home before proceeding with Resident #11 discharging home. The MDS Coordinator confirmed she relayed the care plan meeting information to the Social Worker (unaware of what date that occurred), but there was no documentation to state the conversation between the MDS Coordinator and Social Worker had taken place. During an interview on 1/10/2023 at 3:30 PM, the Nurse Practitioner (NP) stated she was notified by the Social Worker when residents were being discharged . The NP stated she was not involved in the discharge process. The NP stated the Social Worker arranged home health needs, medical equipment needs, and verified with family the details of the discharge, documented the information on a form and gave the form to the NP. The NP reviewed the resident's medication list and printed the transfer discharge record. The NP printed a hospital summary, if pertinent, and last labs and put the documents in a discharge packet. She stated there should be 1 discharge packet for the resident or family and 1 packet for the facility. The NP stated if the family was present at the time of discharge, she would review the discharge papers. Otherwise, it was the nurse's responsibility at the time of discharge. The NP confirmed if the family was not home at the time of discharge, she would not have left Resident #11 at her home unattended. She stated the Social Worker told her Resident #11 was going to be discharged and the family had agreed to the discharge. The NP confirmed she was unaware Resident #11 was discharged without family supervision. The NP confirmed she did not discuss the discharge instructions or medication instructions with Resident#11's Responsible Family Representative as previously documented in her progress noted dated 12/8/2022. The NP stated .it was documented in error . During an interview on 1/10/2023 at 4:00 PM, Administrator #1 stated in this facility, if a resident had a BIMS score greater than 8, the resident could make their own decisions. He stated the Social Worker coordinated the discharge and .gets with the NP . The Administrator stated he had not been involved in the discharges. He stated Resident #11 wanted to go home and she could make her own decisions based on Resident #11's last BIMS score. The Administrator stated he was unsure what Resident #11 could do for herself. He stated the Social Worker called him after the resident had been dropped off at her residence. He stated he was unaware the resident had not received adequate discharge instructions and Resident #11's family was not present at the home at the time of the resident's discharge. Administrator #1 stated it was the Administrator's responsibility to ensure all residents at the facility had a safe transfer or discharge. The Administrator stated the Social Worker, and the NP usually made the decisions of a resident being discharged . During an interview on 1/10/2023 at 4:50 PM, the Medical Director confirmed Resident #11 had substantial Dementia, had poor problem-solving skills and poor insight. The resident was not capable or competent to be discharged without a caregiver. The Medical Director stated she was unaware Resident #11 was discharged without discharge instructions or without notification to the Responsible Family Representative. The Medical Director stated a BIMS score greater than 8 alone was a .single slice of time . and not enough information and evidence to base a decision of resident competence on. The Medical Director confirmed Patient #11's discharge from the facility to the resident's home was not a safe discharge. During an interview on 1/11/2023 at 9:50 AM, the Regional Clinical Regulatory Compliance Risk Manager confirmed Resident #11 was sent home without notification to the family or family representative. She stated discharge planning should start on admission. She stated it was not a common practice to discharge residents in staff private vehicles. She stated it was her expectation for residents and/or family representatives to receive discharge instructions prior to being discharged . She stated this was not a safe discharge for Resident #11 and the facility's policy and procedure for discharge was not followed. The interview revealed there was not sufficient preparation for Resident #11's discharge from the facility on 12/8/2022. During an interview on 1/11/2023 at 3:52 PM, the DON confirmed Resident #11 had no discharge care plan and there was no documentation of a discharge care plan discussion. She stated .I've never been very big in the discharge process as a DON . During a telephone interview on 1/12/2023 at 8:42 AM, Resident #11's Responsible Family Representative stated he received a call from his [AGE] year-old stepson on 12/8/2022 that someone was trying to get in the house. He stated he instructed him to keep doors locked and keep out of sight and call the police. When he returned to the residence on 12/8/2022, he found Resident #11 at the home. He stated he notified hospice to visit, and they could not find the resident's medications or discharge instructions. He stated he was upset there were no discharge instructions or medications to be found, so he called the facility on 12/8/2022 to inquire about the discharge instructions and medications and did not hear back until the following day (12/9/2022). When he got the phone call from the facility (unsure who he spoke with) on 12/9/2022, he was informed the discharge instructions and medications were left in a drawer. He stated the resident did not receive any medications until the afternoon of 12/9/2022. He stated the resident had a decline about 3 days after discharge. Resident #11 had stopped eating and drinking and was more confused and was wandering around the house looking out the front door. He contacted and requested a hospice visit. The hospice nurse visited, and they started her on an antibiotic to treat a possible urinary tract infection. The resident was taken to the hospital and was admitted for a change in mental status, and the hospital stated that her dementia had worsened. The resident stayed in the hospital until she was transferred to a different nursing home on 1/5/2023 and was currently residing at a different nursing home. Review of the facility's documentation showed there were 2 care plan meetings regarding Resident #11's discharge from the facility: a meeting on 8/25/2022 and a meeting on 12/1/2022. Resident #25 was admitted to the facility on [DATE] with diagnoses including Left Below Knee Amputation, Cellulitis of Left Lower Limb (Amputated Stump), Pressure Ulcer of Stump, and Type 2 Diabetes. Review of the 5-day MDS assessment, dated 12/15/2022, showed Resident #25 was cognitively intact with a BIMS score of 14, was wheelchair bound, and required limited assistance of 1 person for transfer. Review of the Comprehensive Care Plan, dated 12/16/2022, showed .ADL, self-care performance deficit r/t [related to] weakness, left BKA [below knee amputation] with cellulitis and pressure ulcer, lack of coordination, use of prothesis to left leg, difficulty walking, extensive assist with adls .Focus .Pressure Ulcer location .Left Lateral Stump Unstageable . and the interventions included Current treatment per order . Further review showed .Return to Community Care Plan .wants to return home. Discharge planning r/t [related to] desire to return home when appropriate . Review of Resident #25's initial Pressure Wound Note from day of admission, 12/9/2022, revealed Resident #25 had 1 pressure ulcer identified on the left lateral stump that was Unstageable and measured 5.5 cm (centimeters) in length, 4.5 cm in width, and 0.3 cm in depth with 90% slough (dead) tissue present in the wound. Review of the resident's weekly Pressure Wound Note, dated 1/2/2023, revealed the left lateral stump pressure ulcer remained Unstageable and measured 4.5 cm in length, 3.5 cm in width, and 1 cm in depth with 20% slough. Review of the treatment orders for the left lateral stump pressure ulcer revealed the orders were changed on 1/2/2023, to Treatment to the left lateral stump (unstageable) [pressure ulcer] cleanse with NS [normal saline] - apply hydrogel soaked gauze and cover with 6x6 [6-inch by 6-inch] border dressing daily and PRN [as needed] if soiled. Every day shift for Wound Healing. Review of the facility's nursing Discharge summary, dated [DATE], showed under Special Treatment, Wound Care was checked. Further review of the Summary included .Discharge Instructions provided .Education (Select all that apply) . Continued review showed no indication there was a need for supplies to be sent with the resident on discharge and no dressing change education was provided. Continued review showed there was no indication education was provided for skin care and treatments. Resident #25 was discharged from the facility on Friday, 1/6/2023. Review of Social Service's resident discharge instructions, dated [DATE], showed Home Health Company: [name of agency] with a phone number provided and indications Home Health was needed for Skilled Nursing, and evaluation for therapy (Physical and Occupational Therapies). During a telephone interview with Resident #25 on 1/10/2023 at 10:45 AM, he stated, .Friday morning [1/6/2023] was the last time it [pressure wound] was bandaged .[dressing] stayed on till yesterday [1/9/2023]. I had one bandage [supplies] to change yesterday .I called [facility Social Worker] 2 to 3 times since yesterday .[the facility] was supposed to have set up home health for me .she [the Social Worker] told me to call the [home health agency phone number] on my discharge papers Monday [1/9/2023] to set up a time for home health .it was the wrong office. It's for [name of city] and I live in [name of city] .[home health agency] said they couldn't take me .I called [the facility Social Worker] and she said she would fax [name of a second home health agency] .later in the day [name of second agency] said they didn't get a fax .called [Social Worker] back again to make sure she had the right fax number .I still haven't heard anything else from her or them .I'm afraid my leg is going to get infected again .I can't drive .because of swelling. I can't get my prosthesis on . During an interview with the Director of Nursing (DON) on 1/10/2023 at 1:20 PM, accompanied by the Social Worker, the DON stated Resident #25 had been referred to a third home health agency on 1/10/2023. During an interview on 1/10/2023 at 3:30 PM, the NP explained the discharge process she had developed with the Social Worker. The NP stated she was notified by the Social Worker when a date for the resident's discharge was projected. The NP stated she was at the facility 5 days each week and &[TRUNCATED]