Inspection·February 29, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to provide a written copy of the transfer notice to residents and the Office of the State Long Term Care Ombudsman (LTCO) for 2 (Residents #388, and #389) of 28 sampled residents transferred to the hospital and subsequently discharged from the facility. The findings included: The facility policy dated October 2022 titled Transfer or Discharge, Facility Initiated stated, Residents have the right to remain in the facility. Facility initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long term care ombudsman when practicable; Notice of Facility Bed Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer; Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. On 2/28/24 at 1:00 p.m., review of the Hospital Tracking Portal log provided by the Director of Nursing (DON) showed 28 residents were transferred to an acute care hospital from [DATE] to 2/28/24. On 2/28/24 at 2:10 p.m., in an interview the Social Services Coordinator said she notifies the office of the Long Term Care Ombudsman each month of all residents discharged home. On 2/28/24 at 2:21 p.m., the Social Services Coordinator provided a fax cover sheet, and discharge information addressed to the office of the LTCO for all residents discharged home. The discharge notifications did not include residents transferred to acute care hospitals. The Social Service Coordinator said she did not know the LTCO had to be notified of transfers to the hospital. She verified the LTCO was not notified of residents transferred to an acute care hospital and had not returned to the facility. Review of Resident #388's clinical record revealed an admission date of 1/15/24. Diagnoses included Acute Renal Failure. The Nursing progress note dated 1/16/24 stated Resident #2 was unable to follow commands, she was still sleepy, and had not been able to drink fluids or eat food. The physician issued an order to transfer the resident to an acute care hospital. Further review of Resident #388's medical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed and given to the resident and the LTCO was notified of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 105856 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Premier Place at the Glenview 100 Glenview Place Naples, FL 34108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)