Citrus Grove Post Acute

coordinator came and assessed Resident 1 several times prior to Resident 1's discharge on [DATE].

The SSD denied that she had any communication with the RABM prior to Resident 1's discharge. On December 31, 2025, at 1:27 p.m., a telephone interview was conducted with the third-party Business Development Director (BDD).

The BDD stated that he was working with the facility for Resident 1's placement.

The BDD stated he provided room and board contact information to Resident 1.

The BDD stated he met Resident 1 in person and was unaware of the care needs for Resident 1. On December 31, 2025, at 1:52 p.m., a telephone interview was conducted with the Enhanced Case Manager (ECM) with the [name of foundation].

The ECM stated that the foundation assists unhoused people with housing, healthcare, and personalized support.

The ECM stated that he was assisting the facility with a safe discharge for Resident 1.

The ECM stated that Resident 1 did not meet the criteria for room and board placement because Resident 1 was unable to perform activities of daily living without assistance.

The ECM stated that Resident 1 was discharged from the facility on December 17, 2025.On December 31, 2025, at 2:31 p.m., an interview was conducted with the facility's Director of Nursing, (DON).

The DON stated the room and board manager should assess the resident in person prior to discharge and social services should arrange the discharge after acceptance. On January 13, 2026, at 2:01 p.m., an interview was conducted with the Administrator (Adm) and the Interdisciplinary Team (DON, SSD, and Physical Therapist). -The Adm stated a resident could be discharged to a room and board if they were high functioning, meaning the resident could perform most activities independently;-The SSD stated she provided the third-party representative with a packet for Resident 1 which included a face sheet, physician order, and the physician's History and Physical.

The SSD further stated Resident 1 is wheelchair bound; and-The Adm stated facility staff did not assess the discharge location for Resident 1.A record of Resident 1's Discharge Plan Documentation dated December 17, 2025, indicated .3.

Discharge Location.3a.

Other destination Room and Board.BB.1.

Transportation for Discharge a. W/C [wheelchair] Van.Durable Medical Equipment.15a. wheelchair.D1.

Assistance Level 1.

Bed Mobility [a person's ability to move and reposition themselves while in bed, including rolling, scooting, sitting up from lying down, and lying down from sitting] .2.

Needs Assistance .1b.

Toileting.2.

Needs Assistance.2.

Household tasks (meal prep, bill paying, simple cleaning) .2.

Needs Assistance.3.

Transfers from bed/chair.2.

Needs Assistance .4.

Walking .3.

Dependent.A review of Resident 1's Progress Notes dated December 16, 2025, at 2:04 p.m., indicated SSD received a call from [name of BDD] who states he was able to find resident room and board placement and has it all arranged for him to discharge tomorrow morning 12/17/25.A review of Resident 1's Order Summary Report dated December 16, 2025, indicated .Resident may DC on 12/17/2025.A review of the packet sent to the third-party representative for the RABM included Resident 1's face sheet, the physician's H&P, and the physician orders.

There was no documentation of Resident 1's functional, or ADL status was included in the packet sent to the third-party representative. On January 14, 2026, at 1:43 p.m., an interview was conducted with the SSD, she stated she did not follow-up with the RABM after becoming aware of Resident 1's placement. A review of the facility's policy and procedure titled Discharge Summary and Plan revised December 2016, indicated .10.

Residents transferring to another skilled nursing facility, or who are discharged to a home health agency, long-term care hospital, or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences.

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