Heritage Care Center

Review of Resident R1's clinical progress note date 7/27/25, revealed that he/she would like to be transferred to another facility stating that he/she is familiar with the facility and would like to go tomorrow.

Further review of clinical progress notes on 7/31/25, 8/7/25, and 8/14/25, indicated Discharge Plan (location/with who and services needed): home with paid caregiver.

Review of Resident R1 comprehensive care plan, initiated 7/28/25, failed to reveal any information related to discharge planning or goals of care to return to the community.

Review of Resident R1's physician progress note date 8/18/25, for service date 8/14/25, revealed that goal for him/her to return home with caregivers pending therapy progress and ongoing evaluation by IDT (interdisciplinary team).

Further review of physician progress note dated 8/28/25, for service date 8/21/25, revealed that he/she told physician he/she will be going home Saturday and does not have any concerns regarding discharge.

Further review of clinical record failed to reveal any progress notes or documentation regarding Resident R1's discharge plans or goals; failed to provide evidence that the facility obtained a physician's order for discharge; and failed to provide evidence that the facility documented and provided resident or caregiver(s) a discharge summary to include a post-discharge plan of care.

During an interview on 9/10/25, at 12:40 p.m., the Director of Nursing (DON) confirmed that the facilityfailed to develop and implement discharge planning processes that focused on residents discharge goals for one out of three discharged residents sampled (Resident R1). 28 Pa.

Code 201.14(a) Responsibility of licensee28 Pa.

Code 201.18(b)(1) Management28 Pa.

Code 201.29(a) Resident rights.28 Pa.

Code 211.10(a) Resident care policies.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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