F0628

E

Failure to Provide Timely and Proper Transfer/Discharge Notices to Residents, Representatives, and Ombudsman

Williamsville, New York Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow required transfer and discharge processes, including written notification to residents, their representatives, and the State Long-Term Care Ombudsman at least 30 days prior to transfer or discharge. The facility’s policy "Discharge Plan - Discharge Instructions" required that each resident with an anticipated discharge date receive necessary information and connections to outside services, and that each department interview the resident and continuing care provider to assess post-discharge needs and develop a plan. Despite this, three residents reviewed for transfer or discharge did not receive proper written notices or complete discharge planning consistent with regulatory requirements.

Resident #3 had dementia, type II DM, and depression, and their MDS dated 10/13/2025 documented that they were cognitively intact, always understood, and always understood others, with no active discharge plan indicated. A single progress note by Social Worker #1 on 11/17/2025 stated that the representative had been informed the facility planned a lateral discharge to a more secure locked unit and that the resident would transfer to the first facility with an open bed. Social Worker #1 later stated the resident was discharged because they required a more secure unit due to dementia and wandering, but could not locate documentation of recent wandering behaviors or recent wandering/elopement assessments and could not recall who had reported the elopement risk. The transfer/discharge notice for this resident was dated 11/13/2025, cited that the resident’s needs could not be met at the facility, and indicated a lateral transfer to a secure locked unit, but the resident/representative signature line was blank, and there was no evidence the representative received written notice 30 days in advance. The nutritional section of the IDT discharge instructions dated 11/14/2025 for this resident was not completed.

Resident #4 had dementia, bipolar disorder, and anxiety disorder, and their MDS dated 09/12/2025 documented that they were cognitively intact, always understood, and always understood others. This resident was discharged on 11/14/2025, and the discharge notice was completed and dated 11/13/2025 by Social Worker #1, but the resident signature line was blank, with no indication of written notice being provided 30 days prior to discharge. Resident #5 had polyneuropathy, bipolar disorder, and anxiety disorder, with an MDS dated 10/16/2025 showing they were usually understood, always understood others, and were moderately cognitively impaired. A late-entry progress note by Social Worker #1, effective 11/17/2025, documented that the resident was notified of discharge and given the discharge notice and summary upon discharge, although the resident had actually been discharged on 11/14/2025. The discharge notice for this resident was dated 11/13/2025 and the resident signature line was marked "Verbal Consent" instead of containing the resident’s signature. This resident later filed an appeal and was readmitted. In an interview, this resident stated staff did not tell them they were moving, that staff came into the room the morning of the move, packed them, and moved them, and that they had to beg to return.

Interviews with facility staff and the Ombudsman further described failures in the notification process. Social Worker #1 stated they believed they spoke with Resident #3’s representative on 11/11/2025 about the planned discharge and allowed time for the representative to research two facilities, but did not call the representative prior to the actual move, despite the representative’s request to be notified so they could be present. Social Worker #1 acknowledged that the representative later complained about not being notified of the timing of the move and not receiving a written transfer/discharge notice. Social Worker #1 also stated they sent transfer/discharge notices to the Ombudsman and that three residents, including Residents #3, #4, and #5, were discharged to the same facility on 11/14/2025. However, the email to the Ombudsman with attached discharge transfer notices was dated 11/18/2025, after the transfers had occurred, and the Ombudsman reported they had not been receiving discharge notices from the facility and had only received one notice since July 2025. The Ombudsman stated that residents and their representatives should receive written notice 30 days prior to transfer or discharge and that the Ombudsman should receive a copy the same day, and also noted that the forms used by the facility prior to 11/17/2025 were outdated and did not meet current regulatory requirements.

The Administrator stated that if a resident was agreeable to a move, the facility did not believe a 30-day transfer/discharge notice was required, and that if a resident was responsible for themselves, family would not need to be notified of a transfer. The Administrator also stated that they would only issue a 30-day transfer/discharge notice to a resident who was discontent with leaving the facility. The Ombudsman, who also served at the receiving facility, reported learning of the moves of four residents to the other facility after receiving calls from family members and the receiving facility that the residents were unhappy about the move. Overall, the record review and interviews showed that the facility did not provide timely, complete, and properly documented written transfer/discharge notices to the three residents and their representatives, nor did it send copies to the Ombudsman at least 30 days before the transfers or discharges, as required by 10 NYCRR 415.3(i)(1)(i–vii).