§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
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Observations:
Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure appropriate social services were provided to ensure a safe discharge to home for one of the two residents reviewed (Resident CL1).
Findings include:
Review of Resident CL1 diagnosis list includes the following diagnoses: Altered mental status (Unusual changes in a person's emotional response, thinking, and behavior) and Metabolic Encephalopathy (A non-traumatic brain dysfunction caused by illnesses or chemical imbalance, resulting in altered mental status).
Review of Resident CL1's "Admission Visit Physician Orders", dated December 4, 2025, revealed "Resident is not capable of understanding rights and exercising own rights".
Interview with Licensed Employee E3 was conducted on February 2, 2026, at 11:00 a.m. Employee E3 reported being the social worker (SW) assigned to Resident CL1. It was further reported that Resident CL1's emergency contact was an ex-husband who does not reside with the resident but aids with the resident's bills and finances. Employee E3 confirmed that the resident does not have a POA (Power of Attorney A legal document that authorizes an "agent" to act on behalf of a "principal" for financial or medical matters). The residents had been deciding for themselves before hospitalization.
Review of nursing progress notes revealed a note dated December 10, 2025, at 8:04 p.m., stating "resident continues with frequent confusion/disorientation".
Review of nursing progress notes revealed a note dated December 11, 2025, at 7:25 a.m., stating "Staff report "[the resident]" is increasingly confused, found in the hallway carrying their purse saying they didn't know where their room was".
Review of nursing progress notes revealed a note dated December 12, 2025, at 10:07 a.m., stating the resident's insurance company notified the facility of the resident's last cover date, which is December 13, 2025.
A review of the Nurse Practitioner's (NP) notes dated December 12, 2025, revealed: Assessment and Plan - Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life) associated with alcoholism, oriented only to self. The same note revealed SLUMS (The Saint Louis University Mental Status- Examination for detecting mild cognitive impairment and early dementia) done in the facility was 16 out of 30. Further note review indicated "[The Resident]" exhibits memory impairment and tangential (Someone whose conversation wanders off topic, bringing irrelevant details, without returning to the original point, failing to answer the question asked) thought process. Further review of the same notes revealed "Resident is not capable of making sound medical decisions. There is concern regarding discharge plan as they live alone with limited support". History of Present Illness revealed "[The resident]" has a marked severe level of impairment, demonstrated by a SLUMS score of 16 out of 30 indicatives of dementia. "[Name of insurance]" gave an insurance cut, but due to concern for a safe discharge plan as they live alone in a dilapidated trailer with unsanitary living conditions, peer-to-peer was done by this provider with extension until December 17, 2025. The resident has limited support with an ex-husband who is minimally involved".
Review of the social services (SS) notes revealed a note dated December 12, 2025, at 12:57 p.m., stating "SS attempted to discuss discharge plans with "[resident's name]", though the resident presented confused, stating they had a two-story home and a manufactured home". Same note revealed "[The resident]" stated that ex-husband "[name of ex-husband]" assisted them and that ex-boyfriend "[name of ex-boyfriend]" was staying in the two-story home with them, the SS will continue to discuss discharge options with "[resident's name]".
Interview conducted with Employee E3 on January 2, 2026, at 1:00 p.m., revealed resident initially reported residing in a two-level house, then informed SS that they live in a mobile home. Employee E3 reported that the ex-husband reported concerns with the resident's home due to holes and some soft spots on the floor. The SS reported that the information, both provided by the resident and the ex-husband, was not verified by the facility. The SS reported rehab previously did home check, but not anymore.
Interview with the rehab director, Employee E4, was conducted on January 2, 2026, at 1:30 p.m. Employee E4 reported that Resident CL1 was physically cleared by rehab but had cognitive impairment, making residents unsafe to go home. Employee E4 confirmed by getting mixed information between the resident, who claimed to live in a two-story house, and the ex-husband, who reported resident lives in a trailer. Employee E4 reported not doing a house check to ensure Resident CL1 will have a safe home discharge. Employee E4 stated, "It's a base-to-base case, it was a quick discharge due to insurance cut, and the resident does not have anyone to drive them home".
Review of Resident CL1's Physician orders revealed an order dated December 18, 2025, for "Stable for discharge with support services".
Social services notes dated December 19, 2025, at 4:03 p.m., revealed "SS contacted the Office of Aging to report unsafe discharge for "[Resident name]". SS spoke to a caseworker and provided the concerns regarding the safety/cleanliness of the home as well as the current mental status/increased confusion".
Further review of Resident CL1's nursing progress notes revealed a note dated December 21, 2025, stating the resident was discharged home, accompanied by the ex-husband, despite the facility's knowledge that Resident CL1 was not safe to go home due to their impaired mental status and safety concerns at the resident's mobile home.
Review of Resident CL1's Discharge Summary, dated December 21, 2025, revealed the facility arranged for homecare services with [name of home care company] for nurse, aide, and social services visit and evaluation once discharge.
An interview was conducted with licensed SS Employee E5 on January 2, 2026, at 1:00 p.m. Employee E5 confirmed that there was no follow up made to the resident after being discharged on December 21, 2025. Employee E5 reported last hearing from [name of the hospital] that resident CL1 was sent back to the hospital a few days after being discharged home.
The above findings were conveyed to the Nursing Home Administrator and Director of Nursing on January 2, 2026, at 2:00 p.m.
The facility failed to ensure Resident CL1 was provided with all social services to ensure a safe discharge to home.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.12(d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 03/03/2026
1. No corrective action could be taken as Resident CL1 was discharged home on December 21, 2025. Although no correction could be taken, a comprehensive review of CL1 discharge was conducted by IDT.
2. To ensure no other residents were affected, a 100% audit of all residents discharged within past 30 days was conducted. No other residents were identified during the audit which would indicate concerns regarding Medially related Social Services.
3. Ephrata Manor's Discharge Policy was reviewed for appropriateness and accuracy to ensure discharge planning meets the overall needs of the resident returning to the community. On February 3, 2026, the Administrator provide education to IDT and Leadership team on the discharge policy and discharge planning procedures. Social Services Department received education on Medically Related Social Services. Medical Director and medical extender will receive education on discharge planning procedures.
4. To ensure ongoing compliance Social Services Director/Designee will audit 100% of home discharges weekly x 4 weeks. Thereafter 10% of home discharges will be audited monthly x 3 months.
5. Results of audits will be reviewed by the Social Services Director/designee to identify trends or patterns and results will be reported at QAPI committee monthly for review and/or further recommendations.
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