Transfer and discharge · Resident Rights Deficiencies
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.
F622 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F622 more often than its own record predicts
Versus expected share1.66×
1.66 times the share F622 takes of citations nationally.
Share of North Carolina citations0.19%
Of every deficiency written in North Carolina in 2025, this is the portion that was F622.
North Carolina0.19%
National0.12%
Share of all citations that were F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F622 findings written in North Carolina, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedJanuary 19, 2021
Based on record review, legal guardian interview, facility staff and hospital staff interviews, the facility failed to communicate Resident #1's guardianship status to the hospital and failed to arrange for a supervised transfer and handoff of Resident #1 who was deemed incompetent and had a legal guardian. The nursing home provided confidential guardianship information to a contracted van driver in a sealed envelope. The van driver reportedly provided the sealed envelope to hospital staff and left the resident alone at the hospital. Hospital staff denied receiving any resident documentation in written, scanned, or telephonic format. This was evident for 1 of 3 residents reviewed for hospital discharges and transfers. …
D · No harm, potential for more than minimal, isolatedApril 24, 2025
Based on record review and staff interview, the facility failed to communicate all required information to the hospital for 1 of 1 resident (Resident #1) reviewed for hospital transfers.
The findings included:
Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of left middle cerebral artery (stroke), dysphagia (difficulty swallowing), and aphasia (absence of speech).
The physician's orders for Resident #1 dated 1/14/25 included a jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine) 16 French (size).
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had no speech. …
B · No harm, potential for minimal, patternJuly 29, 2022
Based on record review and staff interview the facility failed to document a resident's discharge in the medical record (Resident #52) for 1 of 1 resident reviewed for hospitalization s.
The finding included:
Resident #52 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
There was no discharge Minimum Data Set (MDS) available for review.
Review of Resident #52's medical record revealed no order for transfer to the hospital and no documentation of why she was being transferred to the hospital.
Review of a history and physical from the local hospital dated 07/17/22 that Resident #52's assessment and plan included SIRS, acute metabolic [CONDITION(S)], along with other diagnoses. …
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