Health inspection·February 20, 2025

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate discharge planning and assistance for resident ' s safe discharge for one of three residents (Resident 1) by not ensuring home health services (medical services being provided at home) and durable medical equipment (DME-reusable medical devices, equipment, or supplies prescribed by a healthcare provider to assist with the treatment, monitoring, or management of a medical condition or disability) is arranged and confirmed for delivery prior to Resident 1 ' s discharge from the facility. Residents Affected - Few This deficiency resulted in Resident 1 did not receive rehabilitation therapy and the durable medical equipment needed for use at home. Findings: During a review of Resident 1 ' s admission Record dated 12/5/24 indicated that initial admission on [DATE] with diagnoses including Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Dementia (a progressive state of decline in mental abilities), and Difficulty in Walking. During a review of Resident 1 ' s Minimum Data Sheet (MDS-a resident assessment tool) indicated Resident 1 required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on toilet hygiene, shower/ bath, and upper and lower body dressing. Resident 1 ' s MDS also indicated that Resident 1 required partial/ moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on eating, oral hygiene, and personal hygiene. During a review of Resident 1 ' s Physician Order dated 1/2/25, indicated, Discharge to home with Home Health PT/OT (Physical Therapy/Occupational Therapy), HH (Home Health) Nurse for medication and care management. DME: FWW (Front-wheeled Walker) and Compact Wheelchair (lightweight, foldable wheelchair). During a review of Social Service Progress Note dated 1/6/25, indicated Contacted Resident 1 ' s husband with HHPT/OT, HH nursing medication management and care, DME FWW, and discharge transportation as arranged by facility. There were no other concerns. During an interview on 2/19/25 at 3:20pm with the Social Service Director (SSD), the SSD stated she spoke with family and discussed discharge planning and care needs then nursing staff obtained an order for discharge and service requests, but she was not the person arranging and authorization of home health services. The SSD stated the case manager was responsible for the arrangement and was Page 1 of 2 056322 056322 02/20/2025 Montrose Springs Skilled Nursing & Wellness Center 2635 Honolulu Ave Montrose, CA 91020

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unaware as to whether the DME or home health services had been confirmed or arranged prior to the resident ' s discharge. During an interview on 2/19/25 at 4:05pm with the Case Manager (CM), the CM stated she coordinates with other CM from insurance company for authorizing any requests with orders. The CM further stated the resident was admitted required rehabilitation therapy services and was informed during the interdisciplinary team (IDT) meeting of the discharge order. The CM stated arranging medication, home care management, DME, physical and occupational therapy. The CM stated she did not have a chance to request for authorizations and did not follow up for DME or home health services. During an interview on 2/20/25 at 11:20am with SSD, SSD she is responsible in ensuring DME supplies are arranged and provided to the resident prior to discharge and that home health services is confirmed prior to resident being discharged home During an interview on 2/20/25 at 12:12pm with the Administrator (ADM), ADM stated SS and CM have the responsibility to ensure resident are ready for discharge, arrangements are set up, and family support is capable for safe discharge. Social services are required to make a follow up call to make sure Home Health visits and follow up if the resident did not receive the DME at home. During a phone interview on 2/20/25 at 1:45pm with Resident 1's family member, the family member stated the resident did not receive rehabilitation therapy since being discharged home and did not receive any DME supplies. 056322 Page 2 of 2