Failure to Implement Safe and Orderly Facility Closure Plan
Summary
The facility failed to implement an adequate closure plan to ensure the safe and orderly discharge and transfer of all 78 residents prior to closure. Although residents and their families were notified of the facility’s loss of Medicaid participation and impending closure, the facility’s closure plan documentation indicated that residents were given 30 days’ notice and a list of four local nursing homes, along with the option to choose any facility. However, the facility also allowed local nursing home staff to come and screen residents, and the stated goal was to close the facility within 30 days. Despite the written plan, interviews and observations revealed that the facility’s administrator and owner prioritized rapid discharge, with the owner expressing a desire to move residents out as quickly as possible, citing both safety concerns and financial motivations. The administrator stated that residents would begin transferring the day after the closure notice, and the owner later confirmed that all residents were moved within approximately 30 hours, rather than the 30 days referenced in the closure plan. The last resident was observed being transferred to a local hotel, and all residents were discharged within two days of the closure notice. Additionally, the facility failed to provide a policy regarding closure to the survey team, and review of the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing forms for all residents revealed that they were incomplete. The facility’s actions did not align with the stated closure plan or regulatory requirements for orderly and safe resident transitions, and the lack of complete documentation and policy further contributed to the deficiency.
Penalty
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Below are regulatory guidelines relevant to this citation:
The facility did not provide the required 60-day written notice of closure to all residents and their legal representatives. Staff were not informed of the closure in advance, and the ADON was unaware of the notice requirement. All residents were discharged or had passed away before the 60-day period elapsed, and no policy on discharge notices was available when requested.
Surveyors found that the facility did not have a policy or procedure in place for facility closure. When asked, the facility could not provide documentation of such a policy, and the assistant administrator confirmed its absence. This issue had the potential to impact all residents.
The facility did not have written policies and procedures for a facility closure, potentially affecting all 56 residents. The NHA stated that the facility would follow state regulations but acknowledged the absence of a formal policy.
The facility failed to implement proper closure procedures, leading to a rushed and disorganized discharge process for 30 residents. The administrator did not have a closure plan initially, resulting in inadequate communication with residents, families, and the Ombudsman. Essential medical documents were not transferred with residents, causing distress and confusion. The rushed timeline was due to concerns about staff leaving, despite a 60-day notice being claimed by the Regional Director.
The facility failed to have a closure plan, resulting in abrupt notification to residents, families, and staff about the closure. The Owner, lacking a state Administrator license, decided to close the facility without notifying regulatory authorities or providing assistance to residents for relocation. Residents and their representatives were left to make their own arrangements, and the facility Medical Director was not informed until the day of closure.
The facility failed to have a policy and procedure for facility closure or termination of its Medicare/Medicaid Provider Agreement. During an entrance conference, the Nursing Home Administrator and DON could not provide a closure plan. The DON admitted the absence of such a plan, which was previously identified in a past survey. A follow-up interview confirmed the lack of a closure policy.
Failure to Provide 60-Day Written Notice of Facility Closure
Penalty
Summary
The facility failed to provide written notification of impending closure to residents and their legal representatives at least 60 days prior to the closure date, as required. Record review showed that the closure letter was dated September 25, 2025, and residents began being discharged as early as October 1, 2025, with the last resident passing away on October 18, 2025. All 16 residents reviewed for discharge notice did not receive the mandated 60-day written notice. The facility's Nursing Facility Closure Master Resident List confirmed the discharge dates, and no evidence was provided that the required notice was given within the appropriate timeframe. Interviews with the DON and ADON revealed that staff were not informed of the closure until shortly before the letter was sent to families, and the ADON was unaware of the 60-day notice requirement. The facility was unable to provide a policy regarding discharge notices when requested. Observations confirmed the facility was closed as of October 20, 2025, and a sign was posted on the door. The last resident was reported to have been actively dying for about a week prior to passing away in the facility.
Lack of Facility Closure Policy and Procedure
Penalty
Summary
The facility failed to develop and maintain a policy and procedure for facility closure, as required. During the survey, when requested, the facility was unable to provide documentation of a facility closure policy. In an interview, the assistant administrator confirmed that the facility was unable to locate such a policy. This deficiency had the potential to affect all residents residing in the building.
Lack of Facility Closure Policies
Penalty
Summary
The facility was found to lack policies and procedures for handling a facility closure, which could potentially impact all 56 residents. During an interview, the Nursing Home Administrator (NHA) indicated that the facility would adhere to state regulations in the event of a closure but admitted that there was no written policy in place to guide such an event.
Inadequate Facility Closure Procedures Lead to Chaotic Resident Discharges
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures for facility closure, which resulted in a chaotic and rushed discharge process for all 30 residents. The administrator, V1, was informed of the closure on November 4, 2024, and began notifying families and residents without a proper closure plan in place. The facility did not provide timely written notice to the State Survey Agency, the State LTC Ombudsman, or the residents' legal representatives as required by federal regulations. The administrator admitted to not having the closure policy for the first three days and only received it after a surveyor requested it. The facility's actions led to confusion and distress among residents and their families. Residents were informed they had to leave within one to two weeks, despite the official closure date being January 1, 2025. This rushed timeline was attributed to concerns about staff leaving, which would impact resident care. However, the Regional Director of Operations, V19, stated that a 60-day notice was given and that agency staff had been hired to cover potential staff shortages. The Ombudsman, V20, was not properly notified and only learned of the closure through another source, highlighting the lack of communication and organization. The transfer process was poorly managed, with essential medical documents and care plans not being sent with residents to their new facilities. The Director of Nursing, V10, admitted to not sending care plans, MDS assessments, or immunization records, and no report was called to the receiving facilities. Residents and their families expressed feelings of shock, devastation, and heartbreak over the abrupt move, with some residents not being informed of their transfer until it was already underway. The lack of proper planning and communication resulted in a disorganized and distressing experience for all involved.
Failure to Notify and Plan for Facility Closure
Penalty
Summary
The facility failed to have policies and procedures in place that outline the duties of the Administrator in the event of a facility closure. This deficiency was identified through interviews and record reviews, revealing that the facility did not notify the State Survey Agency, the State Long-Term Care Ombudsman, residents, their legal representatives, or the facility Medical Director about the closure. The facility's operation was being conducted by the Owner, who did not hold a state Administrator license, and there was no Licensed Administrator since 7/26/24. Interviews with the Director of Nursing (DON) and the Ombudsman indicated that the decision to close the facility was made abruptly, with the Owner informing the staff on 8/5/24 and deciding on 8/6/24 that the facility would close the next day. Residents were to be moved to a sister facility 2.5 hours away without prior notice to residents, families, or state agencies. The DON confirmed that there was no closure plan in place, and the process was improvised. Residents and their representatives were informed of the closure through informal channels, such as other residents or aides, rather than official communication from the facility. Some residents' representatives had to make their own arrangements for relocation, as the facility did not provide assistance or a list of alternative placements. The facility Medical Director was also unaware of the closure until informed by the DON on the day of the closure.
Lack of Facility Closure Plan
Penalty
Summary
The facility was found to be deficient in having a policy and procedure in place for facility closure or termination of its Medicare and/or Medicaid Provider Agreement. During the entrance conference, the Nursing Home Administrator and the Director of Nursing were unable to provide a closure plan when requested. The Director of Nursing admitted that the facility lacked such a plan and acknowledged that this issue had been identified during the previous full health survey. A follow-up interview with the Nursing Home Administrator confirmed the absence of a policy or procedure addressing facility closure.
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