Shore Gardens Rehabilitation And Nursing Center

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Medical Equipment (DME) was ordered, or any other community referrals were made.A review of SSN written 3/26/25 at 2:24PM, stated, [Resident #6] was discharged to the community. At the time of discharge to the community the resident was given a full reconciled medication list, and instructions to contact his/her PCP (Primary Care Physician) for follow-up. Resident was given transport to the community with all of his/her belongings.There was no other documentation that was provided regarding the plan for Resident #6's 3/26/25 discharge to the community.A review of a Progress Note (PN) written by the Registered Nurse (RN) Supervisor on 3/27/25 at 10:11PM, reflected Resident #6 was back at the facility after going to a local hospital due to a fall at home.During an interview with the Assistant Director of Nursing (ADON) on 8/20/25 at 10:35AM, she revealed that she was not part of Resident #6's discharge planning and was unaware of Resident #6's discharge until the day that the discharge occurred. She further stated that discharges are usually discussed at Utilization Review (UR) Meetings but does not recall if Resident #6's discharge was discussed. She further explained the Administrator, Director of Nursing (DON), ADON, Director of Social Services (DSS), MDS Coordinator, Director of Rehab (DOR), and Unit Managers, attend the UR meetings.During an interview with the DSS on 8/20/25 at 10:55AM, stated that the SW who handled the d/c planning for Resident #6 no longer works at the facility. During the interview she revealed Resident #6 was to be short-term, but did not have any place to go after discharge. The DSS explained the previous SW setup the community discharge at the resident's request to leave. She further stated that Resident #6 was discharged and transported in an Uber to a hotel that was paid for a couple of nights, but unsure of what days. She further stated that she was unable recall if Resident #6's discharge was discussed during the Interdisciplinary Care Team Meetings, where Physical therapy, nursing and social services would discuss

the Resident's care, including the Resident's discharge. The DSS further stated that the facility does not normally discharge to a hotel, and that in her opinion, she would of have the resident stay until there was a safe space for the resident to be discharged . Stated that if a Resident is adamant about leaving, she would have them sign an Against Medical Advice (AMA) form. She was not sure if prior notice of the discharge was provided to Resident #6, because the discharge was Resident initiated, not a facility-initiated discharge. She stated that she does not believe an AMA form was signed due to Resident #6 being medically stable and approved for discharged by the physician. During an interview with the DOR on 8/20/25 at 1:35PM, she revealed that discharges are discussed in the facility's morning meetings. She further explained that when a Long-Term Care Resident is discharged into the community, rehab would do

an evaluation prior to the discharge. She further stated that the rehab department was not notified of Resident #6's discharge, so a discharge evaluation was not completed. Stated Resident #6 was steady while walking, but he needed to rest at times, and had she been notified of Resident #6's discharge, she would have requested a new order for a rollator (a walker with four wheels and a seat).During an interview with the Administrator on 8/20/25 at 2:00PM, he stated that discharges are discussed in both IDCT meetings and UR meetings. He further stated that if a Resident requested to be discharged , then they would have been discussed in IDCT meetings. The Administrator stated that he was not able to recall if Resident #6's 3/26/25 discharge was discussed in their meetings. Administrator further stated that Resident #6 was at Prior Level of Function, and they were cleared by Rehab and Medical, and even though the resident had no other placement, they wanted to leave, and the facility cannot force them to stay. Surveyor informed Administrator that there is no documentation regarding the discussions of Resident #6 wanting to leave or understanding of their discharge location.The facility did not provide any further pertinent information. N.J.A.C. 8:39-4.1(a)30,32

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