Failure to Notify Residents and Representatives of Transfers
Summary
The facility failed to notify residents, their representatives, and the Office of the State Long-Term Care Ombudsman of resident transfers in writing, including the reason for the transfer, date of transfer, location of transfer, statement of the resident's appeal rights, and contact information for the Ombudsman. This deficiency was identified in six out of eleven resident records reviewed. The facility's policy did not adequately document the required notification and appeals information for emergency transfers, and the practice of obtaining signatures from two staff members did not ensure that residents or their representatives were properly informed. Resident 20 was transferred to the hospital on multiple occasions without proper notification to the resident or their representative. The facility's records lacked documentation that the Notice of Transfer or Discharge was provided to Resident 20 or their representative, and the resident was not included in the Ombudsman notification for January 2024. Similar issues were found with Resident 34, who was transferred to the hospital on several dates without proper notification, and the resident was also not included in the Ombudsman report for January 2024. Other residents, including Residents 76, 81, 97, and 184, experienced similar deficiencies. Their clinical records revealed that Notices of Transfer or Discharge were not properly addressed or signed by the residents or their representatives, and there was a lack of documentation in the progress notes to indicate that the information was provided. Additionally, some residents were not included in the Ombudsman notifications for their respective transfer dates. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these deficiencies and the facility's failure to adhere to its policy and documentation requirements.
Penalty
The facility did not issue written transfer or discharge notices to two residents or their legal representatives before transferring them to an acute care hospital. Documentation for both cases lacked evidence of the required notifications, and this was confirmed by the Market Clinical Advisor during the survey.
Facility staff did not provide required notifications to the ombudsman or written notices to residents and their representatives during transfers or discharges to hospitals. In several cases, residents with varying levels of cognitive impairment were transferred without proper documentation or notification, and staff interviews revealed a lack of awareness of these requirements.
A resident was transferred to the hospital for evaluation of shortness of breath, but the facility did not notify the ombudsman as required. The NHA stated they were unaware of the notification requirement, and this deficiency was identified through interviews and record review.
The facility did not notify the State Long-Term Care Ombudsman of hospital and ED transfers for two residents, as required by policy. One resident's hospital transfer and another resident's two ED transfers were omitted from the monthly reports, with staff confirming these events were not reported due to oversight and lack of awareness of notification requirements.
A resident with End Stage Renal Disease and Dependence on Renal Dialysis was transferred to the hospital and later returned, but the transfer was not documented in the Emergency Transfer Log or reported to the State LTC Ombudsman as required. Both the Social Service Director and Administrator confirmed the omission during interviews and record reviews.
Staff did not provide written notification to a resident and their representative upon the resident's transfer to the hospital, instead relying solely on verbal communication as confirmed by both an RN/Unit Supervisor and an LPN.
Failure to Provide Written Transfer/Discharge Notices Prior to Hospital Transfers
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents or their legal representatives prior to facility-initiated transfers to an acute care hospital. Specifically, documentation for two residents showed that each was transferred and subsequently admitted to a hospital, but there was no evidence in their clinical records that a written notice of transfer or discharge was issued to them or their legal representatives. This deficiency was confirmed during an interview with the Market Clinical Advisor, who was unable to locate the required transfer/discharge forms for these residents at the time of their transfers.
Failure to Notify Ombudsman and Provide Written Transfer/Discharge Notices
Penalty
Summary
Facility staff failed to provide timely and appropriate notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman prior to or at the time of transfer or discharge for multiple residents. In several cases, there was no evidence that the ombudsman was notified when residents were transferred to local hospitals or higher levels of care. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman, and documentation supporting such notifications was not provided to surveyors upon request. For one resident with intact cognition, there was no documentation that the ombudsman was notified of the resident's transfer to a hospital. Another resident, who was severely cognitively impaired, was sent to an acute care hospital without evidence of ombudsman notification, and the social worker confirmed she was unaware of the notification requirement. Additionally, a resident with severe cognitive impairment was transferred to a hospital, and again, no evidence of ombudsman notification was found. In another instance, a resident and their representative did not receive written notice of the reason for transfer/discharge, nor was the ombudsman notified. The facility's own policy indicated responsibilities for informing appropriate parties of transfers or discharges, but staff interviews and document reviews showed these procedures were not followed. The survey team discussed these deficiencies with facility leadership, but no further evidence of compliance was provided before the survey exit.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the ombudsman of a resident's transfer to the hospital, as required by federal and state regulations. A resident reported having recently returned from the hospital, and a review of their progress notes confirmed a documented transfer for further evaluation of shortness of breath. During an interview, the Nursing Home Administrator acknowledged being unaware of the requirement to notify the ombudsman about such transfers. This deficiency was identified through resident interview, record review, and staff interview, and was evident for one resident reviewed for hospitalizations.
Failure to Notify Ombudsman of Resident Hospital and ED Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital and emergency department (ED) transfers for two residents, as required by facility policy. One resident experienced a change in condition and was transferred to the hospital, but this transfer was not included in the monthly report sent to the Ombudsman. The omission was confirmed by the staff member responsible for submitting these reports, who acknowledged that the transfer should have been reported. Another resident was transferred to the ED on two separate occasions due to changes in condition and returned to the facility the same days. These ED transfers were also not included in the monthly report to the Ombudsman. The staff member responsible for notifications indicated a lack of awareness that ED transfers required notification to the Ombudsman, resulting in these events not being reported as mandated by facility policy.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for one resident. The resident, who had diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis, was initially admitted on 08/29/2024 and re-admitted on 04/15/2025. Nurse's notes documented that the resident was transferred to the hospital on 03/30/2025 and returned to the facility on 04/15/2025. However, a review of the Emergency Transfer Log for March and April 2025 showed that this transfer was not recorded. During interviews and record reviews with the Social Service Director and the Administrator, both confirmed that the resident's transfer to the hospital was not included in the notification list sent to the State Long Term Care Ombudsman, as required. The Social Service Director acknowledged responsibility for completing and sending the Emergency Transfer Log and confirmed the omission. The Administrator also confirmed that the Ombudsman was not notified of the facility-initiated transfer, which should have occurred.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
Facility staff failed to provide written notification of transfer to a resident and their responsible representative when the resident was hospitalized. Record review showed that the resident was transferred to the hospital, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that only verbal notification was given to the resident's representative regarding the transfer and its reasoning. There was no evidence that written notification was provided as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
