Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
of F623 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025442
Every F623 citation surveyors wrote nationally that year.
Facilities cited438
Distinct nursing homes with at least one F623 finding.
The harm level
How severely F623 is cited
0.2% 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
J—
K10.0%
L—
Actual harm
G40.1%
H10.0%
I—
No harm, potential for more than minimal
D2,13763.6%
E61118.2%
F421.2%
No harm, potential for minimal
A—
B38011.3%
C1865.5%
Every recorded F623 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F623 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.
K · Immediate jeopardy, patternSeptember 20, 2024
Based on interviews, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident or the resident's representative received adequate notice before transfer or discharge for four out of five residents (Resident (R) 3, R4, R13, and R14).
The facility initiated a transfer/discharge based on the facility's inability to meet the resident's needs. However, upon complaint investigation, it was determined by interview and record review that the transfer/discharge was due to the facility needing to move the residents out of their rooms to make space for a new rehabilitation unit. Residents 3, R4, and R13 were selected based on their least likely to have a connection with the community. …
Based on record review, interviews, and facility Transfer and Discharge policy review, the facility failed to provide a 30-day notice of discharge for one (Resident #1) of 2 residents reviewed for facility-initiated discharges, from a total of 4 residents sampled. As a result of the swift discharge from what had become Resident #1's home, he experienced sadness, loss and regret, and had insufficient time to plan for discharge to another location that would meet his physical, emotional and psychosocial needs.
The findings include:
A closed record review for Resident #1 revealed he was admitted to the facility on [DATE] and was [AGE] years old. He was discharged on [DATE]. …
D · No harm, potential for more than minimal, isolatedMay 8, 2025
Based on staff interviews, record review, and review of the facility policy titled, Admission, Transfer, and Discharge, the facility failed to provide a written notification of transfer to the hospital to the resident and resident representative for one resident (R) (R26) reviewed for hospital transfer. This deficient practice had the potential to affect the resident and their representative by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.
Findings include:
Review of the facility's undated policy titled Admission, Transfer, and Discharge revealed that the policy did not provide guidance related to providing the written notification of transfer to the resident and the resident representative. …
B · No harm, potential for minimal, patternJune 4, 2025
Based on record reviews and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 sampled residents transferred/discharged to an acute care facility. ( Resident #13 and #66)
Findings:
1. Documentation in Resident 13's clinical record indicated that he/she was transferred to an acute hospital on 4/2/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written transfer/discharge notice to the resident and/or legal representative.
2. Documentation in Resident 66's clinical record indicated that he/she was transferred to an acute hospital on 5/7/25 and subsequently admitted . …
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Cited in the same inspection, not caused by one another.
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