Failure to Provide Adequate Notice for Resident Transfers
Summary
The facility failed to provide adequate notice before transferring or discharging residents, violating the 30-day notification requirement. Four residents were affected, with transfers initiated under the pretense of the facility's inability to meet their needs. However, it was later revealed that the transfers were to make room for a new rehabilitation unit. The residents were selected based on their perceived lack of community connection, and the transfers were executed without the necessary approval from the residents' State Guardian. The transfers caused significant distress to the residents and their families. One resident, who was cognitively intact, expressed confusion and distress about the transfer, which moved her 80 miles away from her family, making visits challenging. Another resident, with moderate cognitive impairment, was transferred without the State Guardian's approval, despite the guardian's request to delay the transfer until proper procedures were followed. The facility's actions disregarded the guardian's process for approving transfers, leading to a lack of proper oversight and communication. Additionally, a resident with severe cognitive impairment and behavioral issues was transferred to an emergency psychiatric service without proper notification or approval. The facility refused to readmit the resident after a hospital visit, leaving her in a hospital setting until a new placement was found. This action was taken without a written discharge notice or proper communication with the State Guardian, further highlighting the facility's failure to adhere to regulatory requirements for resident transfers and discharges.
Removal Plan
- Social Service spoke with Resident #3's appointed State Guardian and discussed the transfer of Resident #3 to a sister facility. Social Services talked to the Ombudsman and informed them of the transfer. The facility transferred Resident #3 to the sister facility. Resident #3 is no longer a resident of the facility.
- Social Service spoke with Resident #4's appointed State Guardian and discussed the transfer of Resident #4 to a sister facility. Social Services talked to the Ombudsman and informed them of the transfer. The facility transferred Resident #4 to the sister facility. Resident #4 is no longer a resident of the facility.
- Social Services spoke with R13's appointed State Guardian and discussed the transfer of R13 to a sister facility. Social Services talked to the Ombudsman and informed them of the transfer. The facility transferred R13 to a sister facility. R13 is no longer a resident of the facility.
- The facility Administrator reviewed 98 residents currently in-house for facility-initiated transfer/discharge. No facility-initiated transfer/discharge notices were in effect on the 98 residents.
- The Corporate Independent Risk Manager spoke with the State Guardian for the current residents. The Guardian educated the Corporate Independent Risk Manager on the process the State Guardian office must complete before approving a Facility-Initiated Transfer/Discharge of a resident.
- The Corporate Independent Risk Manager educated in a small group setting the President of Clinical Operations, Signature Care Consultant, Regional Social Services, the Administrator, Interim Director of Nursing, Business Office Manager, and Social Services on the process the State Guardian office must complete for a Facility-Initiated Transfer/Discharge of a resident.
- The Corporate Independent Risk Manager created two resource binders to be kept in each Social Service Office. The resource binders would include the steps needed for the state Guardian Office concerning transferring or discharging a resident with an appointed state guardian. If a new Social Service, Business Office Manager, Director of Nursing, or Administrator is hired, they will be trained in orientation by Signature Care Consultant or Corporate Independent Risk Manager on the process the State Guardian office must complete for a Facility Initiated Transfer/Discharge of a resident.
- The Senior President of Quality requested the local Ombudsman to be a member of the newly created Facility-Initiated Transfer or Discharge Subcommittee. The local ombudsman agreed to be a team member on the Facility-Initiated Transfer or Discharge Subcommittee.
- The facility implemented a new procedure concerning Facility initiated transfers or discharges, utilizing a subcommittee of members (Vice President of Operations, President of Clinical Operations, Independent Risk Manager, Signature Care Consultant, Social Services, a nurse or C.N.A. familiar with the resident, the Medical Director, and the Ombudsman. There has not been a meeting scheduled for the subcommittee as there has not been an identified need for a Facility-Initiated Transfer or Discharge in the facility.
- An Ad Hoc Quality Assurance meeting was held with the Medical Director, the Facility Administrator, the Interim Director of Nursing, and the Care Consultant. The Facility Administrator presented the plan and information at the QAPI meeting. The Medical director attended via phone and was notified of the implementation of the facility's improvement plan. The Medical Director reviewed the entirety of the plan and made no further suggestions.
- The Medical Director stated the plan was appropriate. The Facility Administrator will hold a Quality Assurance meeting daily until immediacy is removed. Then, it will decrease to monthly for recommendations and further follow-up regarding the above-stated plan. Moving forward, the Facility Administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee will determine at what frequency any ongoing audits must continue. The Administrator is responsible for implementing this plan.
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.
