Failure to Provide Adequate Notice for Facility Closure
Summary
The facility administrator failed to provide the required 60-day notice of closure to residents, their representatives, and the ombudsman, as mandated by federal regulations. The facility's closure policy was not properly implemented, and there was no documented closure plan available at the time of the survey. The administrator, V1, admitted to not having the closure policy for the first three days after being informed of the closure and only received it after a surveyor requested it. This lack of preparation and adherence to policy led to a rushed and disorganized transfer process for the residents. Multiple residents and their families reported being informed of the facility's closure with significantly less notice than required. For instance, one family member, V2, was notified on November 4th that the facility would close by December 31st, but their relative was transferred just four days later without proper notification. Another family member, V3, was verbally informed of the closure but never received written notice, and their relative was moved unexpectedly from the hospital to a new facility. These instances highlight the facility's failure to provide adequate notice and involve families in the transfer process. The facility's actions resulted in confusion and distress among residents and their families. Several family members expressed frustration over the lack of time to prepare for the transfer and the absence of written communication. The ombudsman, V20, also noted the rapid pace of the closure and the lack of proper notification, as the letter was initially sent to the wrong ombudsman. The facility's failure to adhere to closure policies and provide timely, written notice to all parties involved led to a chaotic and poorly managed transition for the residents.
Penalty
Resources
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The facility failed to provide required written notice of its impending closure to the State Survey Agency, the LTC ombudsman, residents, and residents' RPs, and did not include an approved State transfer and relocation plan. The ADM stated he was out of money, had no closure plan, had not notified residents, RPs, the medical director, or PCPs, and was relying on agency staff while facing non-payment issues. The ombudsman office reported it had not received any closure plan or notice, and the EHR contained no documented resident notifications about the closure or transfer/discharge.
The facility abruptly closed without an approved closure plan or the required 60-day written notice to residents, their representatives, and appropriate agencies. Leadership notified the State Agency by email only a few days before stopping admissions and discharging all in-house patients, relying on verbal communication from case management to inform residents. A guardian reported learning of the closure from media coverage rather than from the facility and received no written notice. Despite a written policy requiring advance notice, regulatory coordination, and individualized, documented discharge/transfer planning with early counseling of patients and representatives, the facility did not produce any written notifications, closure documentation, or accessible records demonstrating that these procedures were followed.
The facility announced its closure without State Agency approval of its closure plan, affecting 53 residents. The closure plan was submitted but not approved before the announcement. Residents received notice of closure but not the detailed closure plan. The administrator confirmed the lack of approval and distribution of the plan.
The facility did not provide the required 60-day advance written notification of its closure to the State Survey Agency and the State LTC Ombudsman, as required by federal regulations. The facility closed with the last resident moved on 09/20/24, but the necessary notifications were delayed due to pending bed expansion approvals at a nearby facility. The facility's closure was confirmed on 10/10/24, and the Ombudsman was not informed until a visit on 09/13/24.
The facility failed to provide timely written notification of closure to residents and their representatives, affecting three residents. A resident with severe cognitive impairment was upset about the move, and his representative received no assistance in finding a new placement. Another resident learned about the closure from a peer, and his representative also received no guidance. A third resident's representative decided to take the resident home after being informed by an aide. The facility did not adhere to its closure policy, which required immediate notification to authorities and residents.
Failure to Notify Residents and Agencies of Impending Facility Closure
Penalty
Summary
The facility failed to submit written notification of an impending closure at least 60 days before the closure date to the State Survey Agency, the State LTC ombudsman, residents, and the legal representatives or other responsible parties of the residents. The report states the facility also failed to include an approved State plan for the transfer and adequate relocation of residents. This deficiency was identified for 28 of 28 residents reviewed for facility closure notices and for 30 of 30 residents reviewed during the closure process. An eviction notice dated 05/08/2026 stated the tenant owed the landlord approximately $430,000, including property taxes, back rent, and advanced operating expenses not repaid, and that the lease would be terminated on July 1, 2026. During interview, the ADM stated he was the only owner, was out of money, and did not have a closure plan at that time. He stated he intended to file for bankruptcy, had not notified residents or their responsible parties about the eviction, and had not notified the medical director, residents' primary care physicians, or responsible parties of the impending closure. The ADM stated direct care staff were being paid through agency staffing companies, but one agency had already cut off service due to non-payment and another had been given a payment deadline that was later extended. He also stated he was delinquent in payment for supplies and pharmaceuticals and that closure felt imminent. The Ombudsman Volunteer stated the ombudsman office had not received any closure plan or notification from the facility. Review of the resident roster showed 30 residents remained at the facility, and review of the EHR showed no documented notifications to residents about the closure and need for transfer or discharge.
Abrupt Facility Closure Without Required 60-Day Written Notice or Coordinated Relocation Plan
Penalty
Summary
The facility failed to develop and implement an adequate plan for relocation and failed to provide written notification at least 60 days prior to closure to residents, resident representatives, and appropriate parties. The facility president reported that the State Agency was notified by email only two days before the closure due to financial concerns, and that residents were informed verbally by case management without any written documentation. All residents were discharged by the stated closure date, and the surveyor was not provided with any written letters or notifications related to the closure, despite requesting such documentation. A state guardian for one resident stated she did not receive written notification and only learned of the closure from the news before calling the facility to confirm. The facility’s own policy required that any temporary suspension, reduction, conversion, or permanent closure of a hospital unit be conducted in a safe, legally compliant manner with advance notice to the Hospital and Facilities Review Board, the Illinois Department of Health, and other impacted agencies, and that for a permanent hospital closure at least 60 days’ notice be provided. The policy also required early, documented counseling of patients and legally authorized representatives regarding transfer plans and anticipated discharge dates. During the survey, there was no access to resident computer records and no policies or procedures specific to unit/facility closure were provided beyond the undated policy reviewed. The abrupt closure occurred without an approved closure plan, without the required written notifications, and without documented individualized discharge or transfer planning as outlined in the facility’s own procedures.
Facility Closure Plan Not Approved Before Announcement
Penalty
Summary
The facility failed to ensure their closure plan was approved by the State Agency before announcing the impending closure. The closure plan, dated 12/30/24, indicated the facility's intent to close with an anticipated closure date of 03/02/25. However, the facility announced the closure on 01/02/25 without having received approval from the State Agency. The administrator, V1, confirmed that the closure was announced and letters were provided to staff, residents, family members, and other relevant parties. Despite this, the facility had not received a response or approval from the State Agency by the time of the announcement. Additionally, the facility did not provide a copy of the closure plan to the residents when they were notified of the closure. Interviews with residents confirmed that they received a letter about the closure but did not receive any detailed closure plan. The administrator acknowledged that residents were not given a copy of the closure plan and stated that they were instructed by the Corporate Office to proceed with resident placement and transfer. At the time of the announcement, 53 residents were residing in the facility.
Failure to Notify State Agencies of Facility Closure
Penalty
Summary
The facility failed to provide the required written notification at least 60 days in advance of its closure to the State Survey Agency and the State LTC Ombudsman, as mandated by federal Medicare and Medicaid regulations under 42 CFR section 483.70. The facility, with a certified capacity of 25 beds, did not send the necessary notifications due to pending bed expansion approvals at a nearby facility where residents were to be transferred. The facility's closure was observed on 10/10/24, with no activity or lighting inside, and the last resident had been moved on 09/20/24. Interviews revealed that the facility's General Counsel and Administrator acknowledged the lack of a closure plan and written notice to the required entities. The Ombudsman confirmed that they were not notified of the closure and only became aware of resident transfers during a visit on 09/13/24. The facility sent a letter on 10/04/24, after the closure, indicating the transfer of residents and the effective closure date. The State Agency Certification and Licensure System showed no evidence of prior notification to the State Survey Agency before 10/04/24.
Failure to Provide Timely Closure Notification
Penalty
Summary
The facility failed to provide written notification of an impending closure to residents and their legal representatives at least 60 days prior to the closure date, affecting three residents reviewed for discharge notice. This failure was identified through interviews and record reviews, revealing that residents and their representatives were not informed in a timely manner, which could impact their access to advocacy services, continuity of care, and appropriate discharge options. The facility's Emergency Nursing Home Closure Policy was not followed, as it required immediate notification to regulatory authorities and written notice to residents and families ideally within 24 hours. Resident #1, a male with severe cognitive impairment and multiple medical diagnoses, was visibly upset about the move and expressed a desire to stay near family. His representative was informed only a day before the planned transfer and received no assistance from the facility in finding a new placement. Similarly, Resident #8, with schizoaffective disorder and other conditions, learned about the closure from another resident and informed his representative, who also received no guidance from the facility. Resident #12's representative was informed by an aide and decided to take the resident home, arranging hospice care independently. The facility's lack of communication and support in these cases highlights the deficiency in adhering to closure notification requirements.
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