Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
of F622 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025126
Every F622 citation surveyors wrote nationally that year.
Facilities cited125
Distinct nursing homes with at least one F622 finding.
The harm level
How severely F622 is cited
3.2% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J90.9%
K—
L—
Actual harm
G202.1%
H10.1%
I—
No harm, potential for more than minimal
D78682.9%
E11512.1%
F40.4%
No harm, potential for minimal
A—
B111.2%
C20.2%
Every recorded F622 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F622 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedApril 11, 2025
Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had severe cognitive impairment, was safely discharged when the facility failed to:
1. Ensure an Interdisciplinary Meeting ([IDT] gathering where healthcare professionals from different disciplines collaborate to discuss a patient's care, develop shared understandings, and coordinate treatment plans) for discharge planning was conducted for Resident 1.
2. Ensure Resident 1 ' s discharge location (house) could meet the resident ' s needs.
3. Follow up with Resident 1 after his discharge from the facility to the house, to ensure Resident 1 was safe and comfortably settled.
4. …
Based on interview and record review, the facility failed to honor a resident's right to a safe, orderly, and planned discharge for one (#1) of one resident discharged while an appeal was pending.
Findings Included:
During a telephone interview on 05/01/2025 at 2:32 p.m., Resident #1 stated she was discharged from the facility on 04/29/2025 while awaiting a hearing discharge. She stated she called to file the appeal on what she thought was the 10th day, but the facility told her she filed the appeal on the 11th day and would still be discharged home. The resident stated she was not ready to come home and could not afford to pay her portion of the bill. She stated she could not go home without a sit- to stand lift which she required for transfers. …
D · No harm, potential for more than minimal, isolatedApril 30, 2025
Based on interview and record review, for 1 out of 36 sampled residents, the facility did not ensure that the transfer was documented in the resident's medical record and that the appropriate information was communicated to the receiving provider. Specifically, the documentation did not include contact information of the practitioner responsible for the care of the resident; resident representative contact information; Advanced Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; a copy of the discharge summary; and all other necessary information to ensure a safe and effective transition of care. Resident identifier: 6. …
B · No harm, potential for minimal, patternFebruary 25, 2025
Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was properly discharged from the facility. This failure had the potential to place Resident 1 at risk for not receiving continuity of care in the hospital.
Review of facility's P&P titled Transfer or Discharge, Facility-Initiated revised 10/2022 showed in the Orientation for Transfer or Discharge (Emergent or Therapeutic Leave) section showed in part for an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: Orient/ prepare the resident for transfer; and prepare for medical record transfer. …
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Cited in the same inspection, not caused by one another.
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