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.
of F625 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025312
Every F625 citation surveyors wrote nationally that year.
Facilities cited311
Distinct nursing homes with at least one F625 finding.
The harm level
How severely F625 is cited
0.0% 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—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D1,56167.0%
E43218.5%
F210.9%
No harm, potential for minimal
A—
B2249.6%
C923.9%
Every recorded F625 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F625 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.
D · No harm, potential for more than minimal, isolatedMay 9, 2025
Based on interview and record review, facility staff failed to provide written notification to the resident and/or the resident's representative of the facility bed hold policy at the time of transfer to the hospital for three residents (Resident #2, #3, and #4) out of four sampled residents. The facility's census was 88.
1. Review of the facility's Bed Hold Policy Guidelines, undated, showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave.
2. …
B · No harm, potential for minimal, patternJune 4, 2025
Based on record reviews and interviews, the facility failed to issue a written bed hold notice to a resident, known family member or legal representative for 2 of 3 sampled residents who had been transferred to an acute care facility (Resident #13 and #66).
Findings:
1. in Resident #13's clinical record indicated that he/she transferred to an acute care hospital on 4/2/25 and subsequently admitted . The clinical record lacked evidence that the facility issued a written bed hold notice to the resident, a family member, or legal representative upon transfer.
2. Documentation in Resident #66's clinical record indicated that he/she transferred to an acute care hospital on 5/7/25 and subsequently admitted . …
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Cited in the same inspection, not caused by one another.
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