F0628

D

Failure to Provide Accurate, Provider-Approved FL2 for Discharge to Assisted Living

Greensboro, North Carolina Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The facility failed to provide an accurate, provider-approved FL2 form to the assisted living facility to which Resident #117 was being discharged, resulting in the resident being denied admission. Resident #117 had been admitted with a right tibial fracture, hemiplegia and hemiparesis following a cerebral infarction, and difficulty walking. An admission MDS showed she was cognitively intact, required partial assistance for wheelchair mobility, and had a discharge goal of returning to the community. Her care plan identified a need for staff assistance with ADLs, use of a quad cane for transfers, and use of a wheelchair, and included a goal to return to the community with coordination between the facility and her physician regarding discharge plans.

An FL2 form signed by Nurse Practitioner (NP) #1 on 5/5/25 documented an assisted living level of care and indicated the resident was semi-ambulatory, with NP #1’s initials noted beside that status. The FL2 also contained three medications that had been struck through, with the medication names rendered unreadable and no indication that NP #1 had approved these changes. The Assisted Living Executive Director later reported that the FL2 he initially received from the facility indicated the resident was non-ambulatory, leading him to rescind the bed offer. The Discharge Planner stated she then corrected the FL2 by changing the ambulatory status from non-ambulatory to semi-ambulatory and striking three medications the resident was no longer prescribed, intending to obtain provider review and signature but acknowledging that this approval had not occurred before discharge.

On the morning of 5/13/25, Transportation Aide #1 transported Resident #117 to the assisted living facility for admission. Upon arrival, the Assisted Living Executive Director met them in the parking lot and stated he could not admit the resident because he did not have an approved FL2. Transportation Aide #1 contacted the nursing facility, and another FL2 dated 5/5/25 was sent, showing semi-ambulatory status with the non-ambulatory box whited out and three medications struck through, but without a provider’s signature approving the changes. The Assisted Living Executive Director contacted the Social Work Assistant and advised that he would not admit the resident because the FL2 changes were not provider-approved. NP #1 later confirmed she had signed the original FL2 on 5/5/25 but had not approved any subsequent changes and that her last working day at the facility was 5/5/25. The Administrator acknowledged that the resident should have remained at the facility until an accurate, provider-approved FL2 was provided to the assisted living facility and stated he did not know why this had not been done.

Resident #117 reported that she was transported for admission on the morning of 5/13/25, was told in the parking lot that she could not be admitted due to missing paperwork, and was then transported back and readmitted to the nursing facility the same day. She stated that at the time of discharge she was able to transfer from wheelchair to bed using a cane and used a wheelchair for longer distances. The Social Work Assistant and Discharge Planner both confirmed that an amended FL2 was sent while the resident was still in the transportation van at the assisted living facility, but that the Assisted Living Executive Director refused admission because the changes lacked provider approval. The resident remained at the nursing facility until 5/17/25, when she chose to discharge home.