F0628

E

Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification

Puyallup, Washington Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required written transfer or discharge notices to residents and/or their representatives, and to notify the State Long-Term Care Ombudsman (LTCO), when residents were transferred to other SNFs or when discharge planning was initiated. The facility’s own SNF Admission Agreement stated that, except in emergencies, no resident would be transferred or discharged without prior consultation with the resident, family/representative, and attending physician, and that a 30‑day advance written notice would be provided for involuntary transfers or discharges. The agreement also specified that written notice must state the reason for transfer or discharge and the resident’s right to appeal. Despite these requirements, surveyors found that multiple residents did not receive written notices, did not receive 30‑day notice, and were not informed in writing of their appeal rights.

For one resident, the representative reported being called and told the resident would be moved because the facility would no longer provide LTC, only rehabilitation services, and that the move would occur the next day. Another emergency contact stated the resident was told late in the day that they would be moved the following day, leaving no time to adjust. The Nursing Home Transfer or Discharge Notice (NHTDN) for this resident showed the transfer date and indicated the notice was given only one day prior. For another resident, the admitting facility DNS acknowledged that the resident’s POA was not notified of the move. The resident’s representative stated they only learned of the move when contacted by the admitting facility to sign papers, and the resident’s sister reported being called in the evening and told the resident would be moved the next day, despite the facility being aware of the POA. Progress notes documented a call to the sister about an accepting LTC facility and agreement to transfer, but there was no indication of written notice to the POA.

Several other residents reported not receiving written notices of transfer or discharge and having little or no advance notice. One resident stated they were not given a discharge notice or informed of appeal rights, and their EHR lacked documentation of written notification prior to discharge to another SNF. Another resident’s nurse’s note documented discharge to a SNF, but the resident and a friend reported only vague or sudden notice and no written transfer notice, and the EHR contained no written notification. Additional residents stated they did not know they were moving until the day of transfer, received no written notice, and were not given a choice of discharge location; their EHRs similarly lacked written notifications. One resident’s POA reported only verbal notice on the day of discharge and no written documentation.

Further, a resident with a care plan goal of LTC at the current facility reported wanting to return home and said staff had recently approached them about discharge planning without providing anything in writing. The resident’s POA stated the social worker had spoken to the resident alone, offered other placements, and that the resident chose one despite being highly confused and unable to make such decisions; the POA confirmed receiving no written notice, even though the resident had been in the facility for about three years and had a spouse/partner also residing there. Another resident who did not speak English had a POA who reported being told by phone that the facility would apply to three nursing homes and move the resident to whichever accepted them, without offering a choice and without written notice or assessment for community placement, and that the resident’s care needs had not changed. The Social Services Director stated that NHTDNs were given to residents at discharge as part of a packet and then uploaded into the EHR, but acknowledged that notices to the LTCO were being sent only at the end of the month, that they were working on an audit and binder system, and that no notices had been sent to the LTCO since they started working at the facility a month earlier. These findings showed that written transfer/discharge notifications and timely LTCO notifications were not consistently provided as required.