Health inspection·June 18, 2025

§483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- §483.15(c)(1)(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A)The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B)The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C)The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D)The health of individuals in the facility would otherwise be endangered; (E)The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F)The facility ceases to operate. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i)Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii)The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. On 5/16/25, an unannounced visit was conducted for the facility's annual recertification survey and to investigate complaints regarding Admission, Transfer and Discharge Rights. The facility improperly transferred Resident 20 to board and care facility (a smaller, more intimate living option for residents who need assistance but not 24/7 nursing care), failed to notify responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or action) in writing at least 30 days prior to the transfer, and failed to advise the RP of Resident 20's of their rights to appeal. The transfer/discharge was improper and violated Resident 20's resident rights. Findings: During a concurrent interview and record review on 5/15/25 at 2 p.m., with Registered Nurse (RN) A, she reviewed Resident 20's clinical records and stated Resident 20 was admitted to the facility on 3/23/18 with diagnosis of Alzheimer's disease (a progressive disease that destroys memory and mental functions), unspecified dementia (decline in mental capacity affecting thinking and social abilities interfering with daily functioning), unsteadiness on feet, history of falling, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose), hearing loss , left ear, Psychotic disturbance, mood disturbance and anxiety (medical condition includes symptoms of intense anxiety or panic that are directly caused by a physical health problem.). Resident 20's RP was his granddaughter as indicated in the Resident 20's face sheet. Minimum Data Set (MDS, an assessment tool) dated 2/14/25 indicated Resident 20's cognition was severely impaired, minimal difficulty of hearing impaired vision, usually understood other and usually understands. Resident 20's physician order, dated 4/24/25, indicated may discharge to board and care on Monday 4/28/25 with home health (a type of medical care provided in a resident's home to function independently) follow up, RN (registered nurse: a healthcare provider who works with medical doctor and others to give the best possible care), Physical therapist (PT: a healthcare discipline that uses movement and physical techniques to treat illnesses), Occupational Therapist (OT: a healthcare discipline that helps individuals with participate in everyday activities). There was no documentation indicating Resident 20's RP had been notified of resident's rights to appeal. Resident 20 had resided in the facility for more than 30 days. During an interview on 5/15/25 at 9:06 a.m., with the RP, she stated that the Social Services Director (SSD) called her on 4/24/25 to inform her that Resident 20 needs to be transferred/discharge due to an alleged abuse at the facility and will keep her in the loop of Resident 20's transfer/discharge in the coming days. The RP stated that she tried to reach out to the SSD because she did not give consent for Resident 20's discharge but did not receive any call back. The RP further stated she received a call back from the SSD on 4/28/25 the day Resident 20 was transferred/discharged in the board and care facility and that was the time the SSD told the RP the address and phone number of the receiving board care where Resident 20 was being transferred. The RP further stated that she was not given anything in writing prior to Resident 20's discharge on 4/28/25 and was not informed of her rights to appeal. During an interview with the SSD, on 5/15/25, at 3:31 p.m., the SSD stated that she was not the one who initially initiated the discharge plan for Resident 20 and she did not notify Resident 20's RP in writing prior to transfer/discharge on 4/28/25. The SSD stated she did not provide Resident 20's RP any advice that she could appeal. The SSD stated she called the RP on 4/24/25 to inform her that Resident 20 needs to be transferred/discharged due to an alleged abuse at the facility and will keep the RP in the loop in the coming days. During a concurrent interview and record review on 5/16/25 at 1:08 p.m., with Certified Nursing Assistant/Activity Assistant (CNA/AA) M, she acknowledged that she was the one who initiated the transfer and discharge of Resident 20 and completed the notice of transfer/discharge dated 4/24/25 using her previous title as Social Service (SS). CNA/ AA M stated that there was no MD (medical doctor)and IDT discussion and documentation that Resident 20 was danger (danger or harm) to others that needs to be transferred or discharged. She further stated that it was her own opinion that the Resident 20 was a danger to other residents. During an interview on 5/16/25 at 1:50 p.m., with the Administrator (ADMN), he stated CNA/AA M was working as SSD on 5/2024 when he started working in the facility as ADMN. The ADMN further stated CNA/AA M status was changed on 2/2025 as CNA/ AA M until now. The ADMN stated CNA/ AA M should not have initiated and completed Resident 20's notice of transfer/discharge dated 4/24/25. The ADMN further stated that Resident 20's transfer and discharge was not safe because the SSD should be the one responsible for the transfer/discharge process in coordination with the IDT. During an interview on 5/16/25, at 2 p.m., with the ADMN, he stated that the SSD was responsible for initiating the process of residents transfer and discharge, and giving 30 day written notice of transfer or discharge. Review of the facility's policy and procedure (P&P) dated 1/2018, titled " Transfer or Discharge Notice" indicated "facility shall provide a resident and /or the resident's representative (sponsor) with a thirty (30) day written notice of an impending transfer or discharge .... Process 1. A resident, and/or his or her representative, will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility ... 3. The residents and or representative will be notified in writing of the following information I. The reason for the transfer or discharge j. the effective date of the transfer or discharge k. The location to which the resident is being transferred or discharged l. A statement of the resident's rights to appeal the transfer or discharge ... information about how to obtain, complete and submit an appeal form; and how to get assistance completing the appeal process." The facility improperly transferred Resident 20 to board and care facility (a smaller, more intimate living option for residents who need assistance but not 24/7 nursing care), failed to notify responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or action) in writing at least 30 days prior to the transfer, and failed to advise the RP of Resident 20's of their rights to appeal. This violation had a direct or immediate relationship to the health, safety, or security of the residents.