Heatherdowns Rehab & Residential Care Center

F 0627 Level of Harm - Actual harm Residents Affected - Few

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

buttock as a rash, was likely misidentified and was a pressure ulcer as determined on 07/29/25 and indicated in the hospital records. During an interview on 09/17/25 at 12:00 P.M., Waiver Service Coordinator (WSC) #302 revealed she was responsible for assisting with arranging care for Resident #62 when she was at home. WSC #302 verified the facility did not contact her to assist with arranging needed services to ensure a safe discharge home for Resident #62. WSC #302 revealed that prior to her initial admission to

the facility in May 2025, Resident #62 was nearly bed bound and required extensive care. During an

interview on 09/18/25 at 10:16 A.M., Certified Nursing Assistant (CNA) #186 revealed Resident #62 had required a Hoyer lift for all transfers since her initial admission in May 2025, and could not transfer on her own. Review of the facility policy titled, Discharge Policy, reviewed August 2024, revealed appropriate discharge planning would be developed based on the resident's medical, physical, social and emotional condition/needs. Available resources would be recommended and made available to provide for the total well-being of the resident and with the approval of the resident's physician. All available local and community resources would be made available and utilized under the coordination of the social services department to ensure that each resident's specific care needs were met upon discharge to maximize the success of each resident. The deficiency was corrected on 08/10/25 when the facility implemented the following corrective actions: On 07/25/25 at 12:30 A.M., Resident #62 was readmitted to the facility. The physician was notified and Resident #62's orders were resumed. On 07/28/25, the DON implemented a discharge checklist, to be initiated upon admission, to verify required services, family/representative/community resource communication, and equipment needs are arranged prior to discharge. On 07/28/25, the DON reviewed the six resident discharges for the previous two weeks, with no negative findings. Beginning on 07/28/25, the Administrator or designee reviewed scheduled discharges daily, Monday through Friday, during the morning clinical meeting to ensure appropriate discharge planning had occurred. Evidence was received to verify discharges were reviewed. On 07/28/25, the DON educated

the Unit Managers (LPN #146 and LPN #204) on the discharge checklist. If SS is not in the facility on the day of discharge, discharge tasks will be assigned to the unit manager or DON to ensure a safe discharge.

Evidence was received to verify the education was completed on 07/28/25. On 07/28/25, the DON assumed discharge planning responsibilities until the new SS begins in the position (expected 10/01/25) and is fully oriented. Beginning on 07/28/25, the Administrator or designee will monitor compliance of a safe and orderly discharge weekly for four weeks. Audits will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to ensure the deficient practice has been resolved. Evidence was received verifying audits were completed weekly/after each discharge, with no negative findings.

Beginning on 07/28/25, the DON or designee will follow-up contact within 24-hours for any resident discharged from the facility to ensure needs were met. Evidence was received to verify completion and is on-going. Upon the new SSD's start date, anticipated 10/01/25, the DON and Social Service Consultant (SSC) #700 will provide orientation, to include safe discharges and utilization of the discharge checklist to ensure a safe discharge. Review of two (#05 and #06) additional closed medical records, reviewed for safe discharge to home, revealed no additional concerns.This deficiency represents non-compliance investigated under Complaint Numbers 2578313 and 2577168.

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