Federal inspectors found the facility failed to follow mandatory notification procedures for residents discharged between late August and early September. The violations affected three of four residents reviewed during a September complaint investigation.
Resident 23 arrived at the facility on August 21 with chronic lymphocytic leukemia in remission, stage four chronic kidney disease, liver cirrhosis, diabetes and a mood disorder. The resident was cognitively intact but displayed verbal behaviors toward others and required staff assistance with daily activities.
When Resident 23 was discharged to the hospital, nursing progress notes contained no documentation that the ombudsman had been notified. The same pattern emerged for two other residents.
Resident 68, also admitted August 21, suffered from atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes and chronic kidney disease requiring dialysis. Despite being cognitively intact with no behavioral issues, the facility again failed to document ombudsman notification when this resident was transferred to the hospital.
The most complex case involved Resident 120, who experienced multiple hospital transfers within weeks. Initially admitted August 12, this resident was discharged to the hospital, readmitted to the facility, then discharged to the hospital again. Medical records showed diagnoses including pleural effusion, stage three chronic kidney disease, liver cirrhosis, atrial fibrillation, diabetes and C. diff infection.
The resident's file contained two admission assessments and two discharge assessments marked "return not anticipated." Yet nursing progress notes revealed no ombudsman notification for either hospital discharge.
When inspectors interviewed the Director of Nursing on September 17 at 2:55 PM, the administrator confirmed the facility "had not notified or had been notifying the Ombudsman of discharges from the facility."
Social Services Director 40 told inspectors during a 3:20 PM interview that the position was new and she "did not know of the notification of the Ombudsman regarding discharge." Only after the inspection began did she call the ombudsman to receive information about required discharge notifications.
The facility's own policy, dated April 20, 2018, states that when the facility determines it can no longer provide needed services and cannot accept a resident back after transfer, staff should refer to the "Notice of Transfer Discharge policy." Inspectors noted this referenced policy was not provided by the facility.
Federal regulations require nursing homes to notify the state ombudsman when residents are discharged. The ombudsman program serves as an independent advocate for nursing home residents, investigating complaints and protecting resident rights during transitions in care.
The inspection occurred at a facility with 79 residents and was prompted by a complaint filed as Number 1382712. All three affected residents had serious medical conditions requiring complex care coordination during their hospital transfers.
Resident 23's medical complexity included cancer in remission alongside multiple organ system failures. Resident 68 required ongoing dialysis while managing heart failure and liver disease. Resident 120 faced the most challenging situation with repeated hospitalizations for fluid buildup around the lungs and a dangerous intestinal infection.
The ombudsman notification requirement exists because hospital discharges represent critical transition points when vulnerable residents need advocacy protection. Without proper notification, residents lose access to independent oversight during periods when they may be unable to advocate for themselves.
The facility's failure affected residents across a spectrum of medical acuity. Some, like Residents 23 and 68, were cognitively intact and could potentially self-advocate. Others faced more complex challenges that made independent advocacy crucial.
The Director of Nursing's confirmation that the facility simply wasn't notifying the ombudsman suggests a systemic breakdown rather than isolated oversights. The Social Services Director's unfamiliarity with the requirement indicates inadequate training or policy implementation.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the breakdown in required advocacy protections occurred during some of the most vulnerable moments in these residents' care transitions.
The three residents experienced multiple medical crises requiring hospital-level intervention. Resident 120 alone faced four facility moves within a month while battling life-threatening infections and organ failure. These are precisely the circumstances when ombudsman advocacy becomes most critical.
Best Care Health and Rehabilitation now faces federal oversight to correct the notification failures and ensure future compliance with resident advocacy protections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Best Care Health and Rehabilitation from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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