Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that copies of discharge notices were sent to the Office of the State Long-Term Care Ombudsman for two residents who were discharged. For one resident, records showed an admission and subsequent voluntary discharge against medical advice, but the facility's emergency transfer log only included notifications for December 2025, and staff confirmed that logs prior to that month were unavailable. For the second resident, records indicated multiple admissions and discharges, including a discharge to the hospital and later to home, but again, the emergency transfer log only covered December 2025, with no access to earlier records. Interviews with facility staff confirmed the lack of documentation and notification for these discharges.