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F0628
H

Failure to Provide Required Written Notice and Documentation for Resident Discharges

Silvis, Illinois Survey Completed on 05-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide required written notifications and documentation related to resident transfers and discharges for 12 out of 14 residents reviewed for facility-initiated discharges. Specifically, the facility did not notify residents or their representatives in writing at least 30 days prior to transfer or discharge, did not record the reasons for the transfer or discharge in the residents' medical records, did not provide statements of appeal rights, and did not send copies of the notices to the Office of the State Long-Term Care Ombudsman. These failures were confirmed through record review and interviews with residents, their families, and facility staff, all of whom reported not receiving any written notice or documentation regarding the discharges. Multiple residents and their representatives described being informed of the need to leave the facility with little to no notice, often by phone call, and without being given a choice or adequate explanation. Some residents were told the facility was being remodeled or restructured, while others were told it was being converted to a mental health facility. In several cases, residents and families reported significant distress, confusion, and lack of involvement in discharge planning. There was no evidence in the medical records of discharge meetings, physician discharge orders, or documentation of the residents' needs or the reasons for discharge. The facility's own policies require written notice, documentation of reasons, and provision of appeal rights, none of which were followed. Interviews with facility leadership and staff confirmed that no thirty-day written notices, statements of appeal rights, or proper discharge documentation were provided. The Director of Nursing, Administrator, and Corporate Social Service Director all acknowledged that discharges were initiated by corporate direction to convert the facility's purpose, and that families and residents were only contacted by phone. The Medical Director was not informed or involved in the discharge process. The Ombudsman was also not notified, and expressed concern about the lack of proper discharge procedures and the impact on residents and families.

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