Brookdale Westlake Hills

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement person-centered care plans that reflected residents’ preferences, goals, and medical, physical, mental, and psychosocial needs for three residents reviewed. Resident #67 was admitted with diagnoses including diverticulitis of the intestine, sepsis, and recurrent major depressive disorder. The resident’s care plan dated 04/02/2026 addressed fall risk, potential skin impairment, pain, and risk for hot liquid injury, but did not include care areas for antibiotics, TPN infusion, JP drains, code status, or PICC line access. The interim care plan also did not address EBP or gastrointestinal issues. The admission skin assessment documented a PICC line in the right arm and two JP drains, and physician orders included JP drain care, PICC line flushing, Clinimix/Dextrose infusion for nutrition, ciprofloxacin for infection, and DNR status. Resident #73 was admitted with diagnoses including adult failure to thrive and severe protein-calorie malnutrition. The interim care plan dated 04/02/2026 did not check feeding tube, gastrointestinal, or EBP/infection. The comprehensive care plan dated 04/03/2026 addressed fall risk, communication problems, ADL self-care performance deficit, and ADD, but did not include care areas for the G-tube or EBP management. Physician orders included bolus enteral feeding through a PEG tube, NPO status, EBP for PEG, and full code status. The MDS nurse stated the interim care plan should have addressed the G-tube because it was important to know how the resident was being fed, and that the admitting nurse did not check feeding tube so the information did not transfer to the comprehensive care plan. Resident #52’s comprehensive care plan dated 03/27/2026 addressed fall risk, potential or actual skin impairment, and a pressure ulcer on the sacrum, but did not address ADL self-care performance deficit or code status. The record also did not reflect EBP status in the care plan. Physician orders later included EBP for a wound and full code status. During interviews, the DON stated baseline care plans should be completed within 24 to 48 hours of admission and should include everything the resident was being treated for. The MDS nurse stated care areas from admission should trigger if the admitting nurse checked the appropriate box, and the admission coordinator stated code status should be put in the resident’s record right away.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications and biologicals stored on medication carts were labeled and stored in accordance with accepted professional principles. During observations of the MC-D and MC-E carts and the NC-E cart, surveyors found multiple medication storage problems, including an undated over-the-counter medication bottle, several open medication bottles without the required month/day/year open date, medication bottles labeled incorrectly, loose unidentified tablets, and medication cups containing unidentified tablets. An expired bottle of Glucosamine Chondroitin was also observed on the MC-E cart with a handwritten note showing it had been opened on 12/17/24. Resident #30 had been discharged from the facility, but two blister packs of Hydrocodone-Acetaminophen remained on the medication cart. The narcotic medication log showed the medication had been delivered in two separate quantities, and staff stated the medication was kept on the cart for the resident to pick up later. Resident #8 had a discontinued Scopolamine transdermal patch still on the medication cart long after the stop date, and staff stated the patch should have been removed immediately when discontinued. Resident #68 had Lantus SoloStar insulin on the cart without an opened date, and staff stated the insulin pen was being used and should have been labeled with the open date. During medication administration, a tablet identified as Metformin was dropped on the floor in Resident #68's room and left there until the ADON picked it up after the surveyor pointed it out. The report also noted that Resident #68's care plan addressed falls, CHF, and ADL deficits, but did not address diabetes and insulin administration. Interviews with nursing and management staff confirmed that open OTC medications should be dated, discontinued and discharged residents' medications should be removed from carts, and loose medications should not remain in medication carts. The facility policy stated that opened medications must be dated, and discontinued, expired, or deteriorated medications for discharged or hospitalized residents must be stored separately until destroyed or returned.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an infection prevention and control program when staff did not perform hand hygiene during medication administration and resident room entry. During observation, MA D did not perform hand hygiene before preparing medications for Resident #55 and went into the resident’s room to administer them without sanitizing hands. After administering the medications, MA D left the room, logged back onto the facility laptop, and started charting without performing hand hygiene. Later the same morning, MA D again did not perform hand hygiene before pulling Resident #48’s medications and going to the resident’s room to administer them. Resident #55 was an older male admitted with diagnoses including essential primary hypertension, chronic kidney disease stage 1, unspecified atrial fibrillation, malignant neoplasm of colon, and malignant neoplasm of prostate. His MDS reflected a BIMS score of 13, indicating he was cognitively intact. Resident #48 was an older female admitted with diagnoses including COPD, atherosclerotic heart disease of native coronary artery without angina, heart failure, and UTI. Her MDS reflected a BIMS score of 15, indicating she was cognitively intact. During interview, Resident #48 stated she would not like it if staff did not sanitize or wash their hands before coming into her room and said it was not acceptable for staff to come to her room after touching other residents without hand hygiene. The report also documented that LVN B did not perform hand hygiene before and after going to Resident #28’s room, which had EBP signs on the door and PPE available at the entrance, and then went directly to Resident #66’s room without sanitizing hands. During interview, LVN B stated he had worked at the facility for over 2 years, had infection control training, and acknowledged that not performing hand hygiene can cause passing germs to other people. Facility staff interviews reflected training on hand hygiene, sanitizing before and after resident contact, and PPE use, and the facility policy stated alcohol-based hand rub is preferred in most clinical situations and should be used before preparing or handling medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that advance directives were clearly identified and documented in the electronic medical record and on the care plan for two residents reviewed for advance directives. One resident was an [AGE]-year-old male with diagnoses including muscle weakness, need for assistance with personal care, hypertension, atrial fibrillation, history of falling, ischemic cardiomyopathy, and heart disease. His admission MDS showed a BIMS of 14, indicating intact cognition. His care plan did not include advance directives, although hospital discharge papers identified him as full code. A second resident was an [AGE]-year-old female with diagnoses including metabolic encephalopathy, protein-calorie malnutrition, vascular dementia, and heart disease. Her admission MDS showed a BIMS of 03, indicating severe cognitive impairment. Her care plan stated that she had an advance directive and documentation in the medical record, but it did not identify code status, and the record review found no code status indicated in the chart. During interviews, the ADON, Admissions Coordinator, and ADM stated that advance directives should be in the resident’s chart on admission and that staff were responsible for entering or scanning the documentation into the medical record. The Admissions Coordinator said she entered residents as full code until DNR paperwork was provided, and the ADM said licensed staff and the IDT were responsible for ensuring advance directives were in the medical file. The facility’s policy stated that upon admission or soon thereafter, the admission coordinator or designee should obtain a copy of advance directives and verify the resident or legal representative’s desired code status.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #67’s drug regimen was free from unnecessary drugs when ciprofloxacin HCl 500 mg was ordered without an appropriate diagnosis or specific indication. Record review showed the resident was an [AGE]-year-old male admitted with diagnoses including diverticulitis of the intestine, other specified sepsis, and recurrent major depressive disorder. His care plan addressed falls, skin integrity, pain, and hot liquid injury risk, but there was no care plan completed for other health concerns such as antibiotic use, TPN infusion, JP drains, code status, or PICC line access. Record review showed Resident #67 had a PICC line in the right arm and two JP drains, one in the left upper quadrant and one in the right lower quadrant of the abdomen. The physician order for ciprofloxacin HCl 500 mg was written for infection for 7 days, but the order did not identify a specific infection, and the MAR also reflected ciprofloxacin without a diagnosis or indication. The facility’s infection control log listed the resident as receiving ciprofloxacin, but there was no area identifying the infection. During interviews, the DON and MDS Nurse stated that antibiotic orders should specify the type of infection so staff can know why the resident is receiving the antibiotic and appropriately assess and monitor the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free of a significant medication error when MA D documented two refused medications as administered. During observation on 04/08/2026 at 5:10 PM, Resident #55 refused 50 mg of Senna and 17 grams of GlycoLax Powder, and the medications were removed from the resident’s room and properly disposed by MA D. However, the MAR for April 2026 documented both medications as administered. Resident #55’s record showed he was an [AGE]-year-old male admitted [DATE] with diagnoses including essential primary hypertension, chronic kidney disease stage 1, unspecified atrial fibrillation, malignant neoplasm of colon, and malignant neoplasm of prostate. His MDS reflected a BIMS score of 13, indicating he was cognitively intact. During interview, Resident #55 stated he did not take the stool softener medications because his stomach had been gurgling and it was uncomfortable, and he said he was cognitively able to make an independent decision about refusing medications. MA D stated refused medications must be documented as refused with the reason for refusal and that the supervisor or charge nurse must be notified. RN A, LVN B, the ADON, and the ADM all stated that refused medications must be documented as not given/refused, discarded, and reported appropriately. The facility policy titled Medication & Treatment- Medication Administration Record stated that if a medication is refused or not given/taken, the associate will document the appropriate chart code reflecting the refusal or reason the medication was not given/taken.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse (LVN B) left a computer at the nursing station unattended with a resident's clinical information displayed on the screen. The information, which included sensitive health details such as diagnoses of hypothyroidism, hypertension, gastro-esophageal reflux disease, and breast cancer, was visible in the electronic health record system (Point Click Care). This action was observed during a survey, and it was noted that the computer screen was not minimized or locked, leaving the resident's personal health information accessible to anyone passing by, including visitors and other residents. Interviews with the nurse revealed that he did not routinely minimize or lock the computer screen when stepping away, relying instead on the computer's automatic screen-off function. He acknowledged receiving HIPAA training at hire and annually, and understood the responsibility to secure the screen. Facility leadership, including the ADON and Administrator, confirmed that policy requires staff to minimize or lock screens when leaving computers unattended, and that monitoring is conducted through observation rounds. Documentation showed that the nurse had attended and acknowledged HIPAA training, which included instructions on protecting patient information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for two residents. Specifically, staff did not properly use evidence-based practice (EBP) personal protective equipment (PPE) during wound care for both residents. Observations revealed that a licensed vocational nurse (LVN) did not wear a gown before starting wound, colostomy, and urostomy care for a male resident with rectal cancer, colostomy, and urostomy, who was also on contact and enhanced barrier precautions. The LVN also failed to sanitize her hands between glove changes and used contaminated gloves to handle clean wound care supplies after cleaning the sacral wound area. Another LVN was observed performing wound care for a female resident with multiple diagnoses, including breast cancer and hypothyroidism, without donning a gown as required by EBP protocols. Both LVNs acknowledged during interviews that they had received training on infection control, EBP, and contact precautions, and were aware of the facility's policies and the importance of following them. The staff admitted to not following the required protocols, citing reasons such as room temperature, but demonstrated awareness of the potential for cross-contamination and infection spread. Facility policy reviews confirmed that the use of gowns and gloves during high-contact resident care activities is required, especially for residents on enhanced barrier or contact precautions. The facility's infection prevention and surveillance policy mandates ongoing monitoring and implementation of infection control procedures, and the hand hygiene policy requires sanitizing hands after glove removal and after contact with residents' skin. Despite these policies and recent staff training, the observed failures in PPE use and hand hygiene during direct care led to the identified deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by the presence of expired supplies in the medication rooms on both the second and third floors. During an observation of the second-floor medication storage room, expired luer locks were found in the storage drawers. Similarly, in the third-floor medication storage room, expired PICC line starters, expired collection swabs, and expired luer locks were discovered on the storage shelves. These findings were confirmed through interviews with LVN A and LVN B, who acknowledged the potential risks of using expired supplies, such as infections, adverse effects, or false results. The facility's policies on the storage and expiration dating of medications and biologicals require regular inspections of nursing station storage areas to ensure proper storage compliance. However, the presence of expired supplies indicates a failure to adhere to these policies. The facility's policy also mandates that medications and biologicals be stored in their original containers, yet the expired items found suggest lapses in compliance with these procedures. These deficiencies could potentially place residents at risk of receiving inadequate treatments or incorrect results.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were fully informed and consented to their treatment, specifically regarding the administration of psychotropic medications. For Resident #8, the facility did not obtain signed consent before administering Depakote, a psychoactive medication prescribed for impulsivity and agitation related to unspecified dementia. Despite the resident having intact cognition as indicated by a BIMS score of 13, the signed consent for Depakote was not found in the medical records until ten days after the medication had been administered. Similarly, for Resident #10, the facility did not obtain signed consent before administering multiple psychotropic medications, including Trazodone, Depakote, and Seroquel. This resident, who had a BIMS score of 15 indicating intact cognition, was under the legal guardianship of a third-party representative. The facility's records lacked signed consents for these medications, and the DON acknowledged that consent should have been obtained from the legal guardian, not the resident. The absence of these consents was noted during a review of the resident's medical records. The Director of Nursing (DON) was informed of the missing consents during an interview and acknowledged the oversight. The facility's process was to obtain informed consent prior to administering psychoactive medications, typically after care plan meetings. However, this process was not followed, leading to the administration of medications without the necessary consents. The Administrator later provided signed consents for the medications, but these were dated after the medications had already been administered.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs. The resident, who was admitted with diagnoses including fracture, cognitive communication deficit, cerebrovascular disease, and muscle weakness, was observed lying in bed with the call light positioned between the bed frame and mattress, making it out of view and reach. This resident had a BIMS score of 7, indicating severe cognitive impairment, and required substantial assistance for activities of daily living. The care plan specifically noted the risk for falls due to general weakness and severe cognitive impairment, emphasizing the importance of having the call light within reach and encouraging its use for assistance. Interviews with facility staff, including an LVN and the DON, confirmed that the call light was not visible or accessible to the resident, which could lead to a lack of care due to the resident's inability to call for help. The facility's policy on resident safety mandates that signal devices be placed within reach, and if a resident cannot use the standard call system, an adaptive device should be used, or frequent monitoring should be provided. The failure to adhere to this policy resulted in the deficiency observed during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles in the third-floor medication room and the Hall E medication aide cart. During an observation, a dosing cup containing 1.5 yellow tablets was found in the medication cart drawer without any labeling. When interviewed, the medication aide was unable to explain the potential consequences of leaving unlabeled pills in the cart. The facility's policy requires regular inspections of storage areas for compliance, and medications should be stored in their original containers. These lapses in procedure could lead to residents receiving incorrect medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage practices. During an inspection of the walk-in refrigeration area, food items such as a cracked egg, a portion of sliced cake, and a red onion were found stored on the floor beneath storage racks, which is against the facility's policy that requires food to be stored at least six inches off the floor. Additionally, individual portions of orange juice were found in the refrigerator with expired dates, indicating they were past their labeled use-by date. The Clinical Dietary Manager confirmed these findings, acknowledging that the items should not have been stored in such a manner and that expired items should not be present in the refrigerator. Further inspection of the chest freezer revealed that individual portions of ice cream were not labeled with the date they were portioned or a use-by date, which is a requirement for maintaining food safety. Moreover, four out of five large tubs of ice cream were observed without sealed covers, which could lead to contamination. The Clinical Dietary Manager confirmed these observations, acknowledging the lack of proper labeling and sealing. The facility's policy and the FDA Food Code 2022 were reviewed, both of which emphasize the importance of maintaining food storage areas free from contaminants and ensuring proper labeling and storage practices to prevent foodborne illnesses.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving residents requiring isolation precautions. For one resident, identified as needing enhanced barrier precautions (EBP) due to a cutaneous abscess and an indwelling Foley catheter, there was no signage or personal protective equipment (PPE) cart present outside the resident's room. This oversight was observed on two occasions, and the Licensed Vocational Nurse (LVN) was unaware of the missing items until it was brought to their attention. The facility's policy required that signs and PPE be available outside the resident's room, but this was not adhered to, potentially compromising infection control measures. In another incident, a Certified Nursing Assistant (CNA) failed to follow contact isolation procedures for a resident with a methicillin-resistant Staphylococcus aureus (MRSA) urinary tract infection. Despite the presence of signage and a PPE cart, the CNA entered the resident's room without performing hand hygiene or donning the required PPE, and subsequently exited the room with a breakfast tray without sanitizing hands. The CNA acknowledged awareness of the contact precautions but did not adhere to them, citing the brief nature of the task as justification. The Director of Nursing (DON) confirmed that all staff had been trained on isolation precautions, yet the CNA's actions did not reflect this training.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified during a review of a resident who had an unwitnessed fall and was subsequently sent to the hospital. Upon returning to the facility, the resident did not receive the required neurological assessments as per the facility's protocol. The protocol mandated neurological checks at specific intervals following an unwitnessed fall, especially given the resident's use of anticoagulant medication and the presence of a hematoma. The resident, who had moderate cognitive impairment and was on anticoagulant therapy, experienced a fall from her wheelchair, resulting in a hematoma and skin tears. Despite returning from the hospital with no new orders, the facility's staff failed to conduct the necessary neurological evaluations. The facility's policy required checks every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the next four hours, every two hours for the first 24 hours, and then every shift for the following two days. However, the resident missed eight neurological checks that were supposed to occur every two hours from the time of her return. Interviews with facility staff, including the ADM, LVN, ADON, and DON, revealed a lack of adherence to the established protocol for neurological evaluations. Staff members acknowledged the importance of these checks in identifying potential changes in a resident's condition, such as a brain bleed or altered mental status. Despite this understanding, the required evaluations were not documented, indicating a failure in following the facility's policy and potentially placing the resident at risk.

Penalty

Inspection fine: $7,800

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement an effective discharge planning process for a resident, leading to significant neglect and an unsafe discharge. The resident, who had no cognitive impairment and required maximum assistance for transferring and other activities of daily living, was discharged without the necessary support and equipment. Specifically, the facility did not ensure that a wheelchair and assistant services were set up upon the resident's discharge to her apartment. As a result, the resident was found by EMS over 24 hours later, unable to transfer herself, lying in the same spot without access to food or water, and in a soiled diaper. This led to the identification of an Immediate Jeopardy (IJ) situation by surveyors, which was later removed after corrective actions were taken, but the facility remained under scrutiny to evaluate the effectiveness of the new systems put in place. The resident's discharge summary indicated that no home health services were recommended, and a wheelchair was to be provided. However, the wheelchair was not delivered on time due to a co-pay issue, and the resident was left without the necessary equipment to move or care for herself. The social worker responsible for the resident's discharge did not confirm the availability of caregivers at the independent living facility and relied on the resident's statement that she would pay the co-pay for the wheelchair once she got home. This lack of verification and preparation led to the resident being left in an unsafe and unsanitary condition. Interviews with facility staff revealed that the discharge process was not adequately followed, and the resident's needs were not properly assessed or met. The social worker and other staff members failed to ensure that the necessary equipment and services were in place before the resident's discharge. The facility's policies on discharge planning and transition care were not effectively implemented, resulting in the resident's neglect and subsequent hospitalization. The facility's failure to provide a safe discharge placed the resident at risk of harm, injury, and rehospitalization.

Removal Plan

• Social Services verified with the Durable Medical Equipment (DME) Company that Resident 1 wheel chair was delivered fully assembled and ready to use at Resident 1's address delivery receipt signed by a caregiver.
• The community Healthcare Liaison contacted the hospital case manager and Resident 1 to inquire about discharge planning from the hospital. Resident 1 was offered to return to the community. The resident accepted and is scheduled to admit.
• Social Services audited actual planned discharges to verify that they include discharge date, location, DME, Home Health, and confirmation of services. Appropriate services were confirmed, and no additional residents were identified to be impacted.
• The Divisional Director of Clinical Operations re-educated the Administrator on the discharge planning process and policies.
• The Administrator and/or designee re-educated licensed nurses the interdisciplinary team (IDT) members, which include therapy, social services, resident programs, nursing management, and the Registered Dietician on completing the transitions discharge summary. The in-services included the Transition Care Conference policy and Transition of Care and Discharge Summary Policy, which will be re-educated before their next scheduled shift. New staff and agency staff will have the training included in orientation. The Administrator re-educated Social Services on listing the date home health has confirmed services and the planned start of care. Re-education includes notification of Adult Protective Services (APS) and Ombudsman for any discharges identified to be unsafe. This notification will be ongoing as part of a systematic change. Licensed Nurses and IDT members including as needed staff who were not available will be re-educated before their next scheduled shift by the Administrator and/or designee. The training will be documented on an in-service form, and competency will be validated by a post-test. The administrator or designee is responsible for administering the post-test and ensuring compliance.
• The community conducted an impromptu Quality Assurance Process Improvement (QAPI) to review the discharge planning process. In attendance were the Medical Director, Administrator, Executive Director, Regional Director of Operations, Regional RAI Director, and Divisional Director of Clinical Operations.
• During the weekly Medicare meeting, the IDT will review the discharge checklist, home health services, and DME as indicated for planned discharges. Social Services will arrange for home health services and order DME as indicated. Social Services will confirm the delivery date of the ordered DME and the start of home health services. The delivery date and start dates will be documented in the medical record. IDT will provide residents with a choice to postpone discharge when services as reported not available greater than 2 days from discharge. This is an ongoing systematic change.
• Social Services and/or designee will complete weekly audits of planned discharges. The audits will be documented on an audit form and the results will be reported to the monthly QAPI Meeting.