Health inspection·December 29, 2025

Complaint Number: 2685335 Representing the Department, HFEN 44583 Citation B was written REGULATORY VIOLATIONS: Code of Federal Regulations, Title 42 F627 §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- §483.15(c)(1)(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §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- §483.15(c)(7) Orientation for transfer or discharge. §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i)A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services (ii)If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. §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. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (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 12/5/25 an unannounced visit was conducted at the facility to investigate a complaint regarding inappropriate discharge. The facility failed to follow their discharge policy for one of three sampled residents (Resident 1) when Resident 1 was not allowed to return to the facility after a doctor's appointment. This failure resulted in Resident 1 being left outside of the facility for at least an hour and a family member had to call the police who called paramedics to send Resident 1 to a hospital. This failure had the potential to compromise Resident 1's health and safety. Findings: Review of Resident 1's clinical record titled, "Admission Record," dated 12/5/2025, indicated Resident 1 was admitted to the facility on 8/7/2025 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), cerebrovascular disease (CVA-stroke, loss of blood flow to a part of the brain), hypertension (HTN-high blood pressure), other amnesia (loss of memories, including facts, information, and experiences), and alcohol dependence, uncomplicated (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking). Review of Resident 1's Nurses Progress Note dated 12/4/2025, indicated, "Resident left facility without out on pass at 13:30 [1:30 PM]. Resident reported to this nurse that he had an appointment with a PCP [primary care physician] outside of the facility. Informed social services. Resident went out of facility without an order from MD [medical doctor]." During an interview with the nurse practitioner (NP) on 12/5/2025 at 1:18 a.m., the NP confirmed she received a message from their group chat on 12/4/2025 at 6:37 p.m., indicated, "patient left AMA [against medical advice] around 2 p.m." NP further confirmed she did not respond to the message because it was already after hours. NP stated nurses should have notified the after hour on-call physician or NP. During a phone interview with licensed vocational nurse A (LVN A) on 12/5/2025 at 1:48 p.m., LVN A confirmed he was the nurse in the evening shift on 12/4/2025. LVN A stated their social services director (SSD) instructed them not to allow Resident 1 back to the facility, and to call 911 to accept him back to the facility. LVN A further stated, Resident 1 was in a cab when he came back around 6:00 p.m. on 12/4/2025, and he was on the phone talking to his sister. LVN A confirmed he did not ask Resident 1 to come back inside the facility, he did not call the DON and their doctor about the situation. LVN A further confirmed he just followed the SSD's instruction not to accept Resident 1 back and he went back to continue with passing medications to his residents. During an interview with certified nursing assistant B (CNA B) on 12/5/2025 at 2:13 p.m., CNA B confirmed their SSD informed the evening staff that Resident 1 left AMA, "she did not go to full details," and instructed them not to allow Resident 1 back to the facility. CNA B stated the SSD handed her the AMA form to provide to Resident 1 if he comes back. CNA B further stated, Resident 1 came back the same day at around 5:30 p.m., she handed him the AMA form, and he told her that he had nowhere to go. CNA B stated Resident 1 was upset, "obviously in disbelief because he just went out to an eye doctor's appointment." CNA B further stated Resident 1's sister called the police, and the police called the paramedics to send Resident 1 to the hospital. CNA B confirmed Resident 1 was outside the facility for at least an hour. During an interview with the SSD on 12/5/2025 at 2:29 p.m., the SSD stated she overheard from staff that Resident 1 went out for an appointment. The SSD further stated, she checked her calendar and Resident 1's physician order and it indicated there was no doctor's appointment scheduled for the day and there was no order that Resident 1 could go out on pass. SSD stated she called her consultant, and she was advised that Resident 1 went AMA. SSD confirmed she initiated Resident 1's AMA form and she instructed the evening shift staff not to accept Resident 1 back to the facility. SSD further confirmed that there was no physician's order related to Resident 1's AMA discharge and she was "just following the AMA situation." During a concurrent interview with the director of nursing (DON) and record review of Resident 1's nurses progress notes dated 12/4/2025, and order summary report on 12/5/2025 at 3:08 p.m., the DON confirmed there was no documentation that the doctor was notified about Resident 1's return and the SSD was the only one notified. The DON further confirmed there was no AMA order. The DON stated she was only notified in the morning of 12/5/2025 that Resident 1 came back and was brought to the hospital. During an interview with the administrator (ADM) on 12/5/2025 at 3:34 p.m., the ADM stated the nurse should have allowed Resident 1 back in the facility, did their assessment, and if Resident 1 needed to be transferred to the hospital, they should have called the doctor and transferred him as needed. Review of the emergency department's (ED) provider note dated 12/4/2025, indicated, "70 y.o. [year old] male...brought to the ED by EMS [emergency medical services] after patient was discharged from his nursing home - [name of the facility]. Reportedly patient has been a resident there for 4 months went to his scheduled ophthalmology [eye doctor] appointment and when he returned his belongings was collected into bags and he was told that he had left AGAINST MEDICAL ADVICE...Differential diagnosis: Abandonment...CLINICAL IMPRESSION: 1. Neurocognitive disorder 2. Suspected victim of abandonment in adulthood, initial encounter..." During a review of the facility's undated policy and procedure titled, "Against Medical Advice (AMA) Discharge Policy - Admissions, Transfers and Discharges," indicated, "Residents, or their responsible party (RP), have the right to request discharge from the facility at any time including against medical advice (AMA). Such discharges are considered resident-initiated discharges and are distinct from facility-initiated discharges. The facility will honor this right while ensuring that required notifications and documentation are completed. Required Notifications...The attending physician or on-call provider must be notified immediately...Documentation: The assigned nurse or designee will document in the medical record: a. The resident's or RP's stated intent to leave AMA. b. Notification of the physician..." This failure resulted in Resident 1 being left outside of the facility for at least an hour and a family member had to call the police who called paramedics to send Resident 1 to a hospital. This failure had the potential to compromise Resident 1's health and safety. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.