Failure to Notify Ombudsman of Resident Hospital Transfers
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for three residents who were discharged to the hospital. This failure prevented the Ombudsman's office from having the opportunity to educate and advocate for the residents regarding the discharge process. The facility's policy required that the LTCO be provided with a copy of the transfer/discharge notices for hospitalized residents, but this was not followed for Residents 60, 49, and 42. Resident 60 was discharged to an acute hospital twice, and there was no documentation indicating that the LTCO was notified for either discharge. Resident 49 was transferred to the hospital due to shortness of breath and low blood-oxygen levels, but again, there was no documentation of LTCO notification. Resident 42, who had medical conditions including unstable blood sugar levels and malnutrition, was transferred to the hospital for further evaluation due to increased confusion, but the facility could not provide documentation showing LTCO notification for this hospitalization either. In interviews, staff members confirmed that the facility's ombudsman notification process was not being followed. The Social Services Director admitted to not completing the state's LTCO notification process or maintaining communication logs in the facility's record. Both the Administrator and the Chief Nursing Officer stated that they expected the social services department to notify the ombudsman of residents' transfer/discharge to the hospital as required, but acknowledged that this was not being done. This lack of compliance with the notification process was a clear deficiency in the facility's operations, as it failed to meet the regulatory requirements for resident discharge notifications.
Penalty
The facility failed to notify the Ombudsman when residents were transferred or discharged, affecting three residents. A resident with cirrhosis and chronic kidney disease, another with malignant neoplasm and candida sepsis, and a third with portal vein thrombosis and major depressive disorder were not reported to the Ombudsman upon discharge. The DON confirmed the oversight, and the facility lacked a notification policy.
The facility failed to provide required transfer/discharge notices to residents and their representatives, affecting four residents who were sent to the hospital without proper notification. The facility's policy requires such notices to be given in an understandable manner, but this was not followed, as confirmed by the administrator.
The facility failed to notify the Ombudsman when two residents were transferred to the hospital. One resident with moderate cognitive impairment was admitted to the hospital multiple times without notification, and another resident with multiple health issues was discharged without informing the Ombudsman. The Social Services Director confirmed the lack of notifications since April 2024, despite facility policy requiring such notifications.
A facility failed to notify the State Ombudsman of a resident's transfer to the hospital. The resident, who had severe cognitive impairment and multiple medical conditions, was not given appropriate transfer notice. The facility's administrator confirmed that they had not been submitting transfer information to the Ombudsman, based on prior communication indicating it was unnecessary.
The facility failed to notify the local Ombudsman of transfers for two residents, one with complex medical issues and another with multiple sclerosis and cellulitis, to the emergency room. Despite documentation of the transfers and provision of bed hold policies, there was no evidence of Ombudsman notification, confirmed by facility staff.
The facility failed to provide written notices of transfer or discharge to residents when they were sent to the hospital, affecting four residents. The deficiency was confirmed through record reviews, staff interviews, and policy reviews. The residents involved had intact cognition, and the facility's policy required a notice of transfer for emergency transfers or discharges, which was not adhered to.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman when residents were transferred or discharged, affecting three residents out of four reviewed for discharge. Resident #69, who had diagnoses including cirrhosis of the liver and chronic kidney disease, and Resident #174, with conditions such as malignant neoplasm and candida sepsis, were not reported to the Ombudsman upon discharge. Additionally, Resident #175, diagnosed with portal vein thrombosis and major depressive disorder, was also not reported. The facility's list of discharged residents for several months did not include these individuals, and the Director of Nursing confirmed the oversight. The facility did not have a notification to Ombudsman policy available for review.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents and their representatives, as required by policy. This deficiency was identified during a review of medical records, staff interviews, and policy review. Four residents were affected by this oversight, as they were transferred to the hospital without receiving the necessary notice of transfer or discharge. The facility's policy mandates that such notices be provided in a language and manner understandable to the resident and their representative, but this was not adhered to in these cases. Resident #78 was sent to the hospital for shortness of breath, Resident #180 for abnormal laboratory values, Resident #181 for an unspecified reason, and Resident #79 for a change in condition requiring evaluation. In each instance, there was no documentation indicating that the residents or their representatives were informed of the transfer or discharge. The facility administrator confirmed the lack of notification for these residents during an interview, highlighting a systemic issue in the facility's adherence to its transfer and discharge policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman when residents were transferred or discharged to the hospital, affecting two residents. Resident #42, who had moderate cognitive impairment and required assistance with daily activities, was admitted to the hospital on three occasions without the Ombudsman being notified. The Social Services Director confirmed that there had been no notifications to the Ombudsman regarding hospitalizations or discharges since April 2024. Similarly, Resident #58, who had multiple diagnoses including cerebral infarction with hemiplegia and COPD, was discharged to the hospital without the Ombudsman being informed. The facility's policy required that a copy of the transfer or discharge notice be sent to the Ombudsman at the same time as it was provided to the resident and their representative. However, this procedure was not followed, as verified by the Social Services Director.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide appropriate transfer notice and ombudsman notifications for a resident who was discharged to the hospital. The resident, who had severe cognitive impairment and multiple medical diagnoses including chronic kidney disease, GERD, and depression, was not properly notified of their transfer, nor was the State Ombudsman informed. The facility's administrator confirmed that they had not been submitting transfer information to the Ombudsman, based on previous communication from an Ombudsman indicating that such notifications were unnecessary.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the local Ombudsman of resident transfers as required, affecting two residents. Resident #57, who had a complex medical history including acute on chronic respiratory failure, seizures, and diabetes, was transferred to the emergency room due to seizure activity and low oxygen saturation. Despite the transfer being documented in the resident's medical record and a bed hold policy being provided, there was no evidence that the local Ombudsman was notified of the transfer. The facility attempted to confirm notification with the Ombudsman's office but was unable to obtain confirmation. Similarly, Resident #65, who had diagnoses including multiple sclerosis and cellulitis, was transferred to the emergency room for an infection in the right lower extremity. The facility also failed to provide evidence that the Ombudsman was notified of this transfer. Interviews with the Senior Director of Nursing and the Regional Director of Operations confirmed the lack of notification to the Ombudsman for both residents' transfers.
Failure to Provide Written Notices of Transfer/Discharge
Penalty
Summary
The facility failed to provide written notices of transfer or discharge to residents when they were sent to the hospital, affecting four residents who were reviewed for transfer or discharge. The facility identified a total of 32 residents who were discharged to the hospital since May 2024. The deficiency was confirmed through record reviews, staff interviews, and policy reviews. The residents involved had intact cognition, as revealed by their quarterly Minimum Data Set (MDS) assessments. Resident #78 was discharged to the hospital on three occasions, Resident #46 on five occasions, Resident #76 on one occasion, and Resident #44 on three occasions, without receiving the required written notices. Interviews with the Regional Administrator confirmed that the facility did not provide the necessary documentation to the residents or their representatives. The facility's policy, revised in August 2022, stated that a notice of transfer should be provided for emergency transfers or discharges, which was not adhered to in these cases.
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.
