Based on interview, and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharges.The facility discharged Resident #1 on 07/21/26 to a private care home that was not aware of the level of care Resident #1 required and the facility did not ensure the private care home could meet his medical needs.The facility failed to follow their discharge planning policy and federal regulations when they did not implement an effective discharge planning process for Resident #1 to ensure his discharge rights were not violated.Resident #1 was located by his legal guardian on 08/13/26 at an unlicensed facility and observed in a… …
F627
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F627 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F627 finding.
The harm level
How severely F627 is cited
7.7% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J284.0% | K— | L— |
| Actual harm | G243.4% | H20.3% | I— |
| No harm, potential for more than minimal | D61787.9% | E284.0% | F20.3% |
| No harm, potential for minimal | A— | B— | C10.1% |
In the surveyor’s words
What an F627 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.
This citation pertains to intake #3109721. Based on interview and record review the facility failed to ensure a safe discharge for one Resident (#12) of three residents reviewed for discharge planning. This deficient practice resulted in hospitalization with sepsis, dehydration, plugged feeding tube, aspiration pneumonia, and hospitalization for Resident #12. Findings include:Resident #12 (R12)According to intake #3109721 filed with the State Agency (SA) on 7/23/26, read in part Individual was discharged from LTC [Long Term Care] to his home.There was no power or running water upon arrival home. The individual was discharged with a Jujunostomy [sic] tube without homecare. The Jujunostomy [sic] was supposed to be set to run 50cc/hr [cubic centimeters/hour] for patency. …
Based on interview and document review, the facility failed to ensure 2 of 3 sampled residents (R39 and R40) had a recapitulation of stay describing the resident's course of treatment while residing in the facility and included, but not limited to, their diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including any pending lab results. Findings include: R39's face sheet identified she was admitted to the facility in December 2023 and discharged [DATE]. …
Based on a review of clinical records, facility documentation, and resident and staff interviews, it was determined the facility failed to develop and implement discharge planning consistent with a resident's expressed discharge goals and demonstrated self-care abilities for one of 28 residents reviewed (Resident 7).Findings included: A review of in-service documentation provided by the facility, dated December 2, 2025, revealed that discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. …
By state — 2025
Where F627 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- California1.89× · 93 citations
- Texas0.93× · 28 citations
Co-occurrence
Cited alongside F627
Of the 2025 surveys that cited F627, these tags appeared in the same inspection more often than chance would predict.
- F62823.7% of F627 surveys · 6.1× chance
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Cited in the same inspection, not caused by one another.
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