The Director of Nursing told inspectors on November 5 that the facility only made phone calls to let families know their loved ones were being moved. No written discharge or transfer notifications were given to residents, families, or their representatives "because it was not something the facility did and was not part of the facility's process or policy."
Federal regulations require nursing homes to provide written notices before any transfer or discharge. The notices must include the reason for the move, the effective date, where the resident is going, and information about appeal rights. Facilities must also send copies to the state ombudsman.
Village Healthcare's own policy, revised in December 2023, acknowledges these requirements. The policy states that if residents or their representatives exercise their right to appeal a transfer or discharge notice, "the facility shall not transfer or discharge the resident while the appeal is pending."
But the facility wasn't providing notices at all.
RN-B, interviewed at 4:05 PM on November 5, said he gave some discharging residents and receiving facilities paperwork that included medications and transfer instructions. He did not give or send any discharge or transfer notifications to families or representatives.
The violation affects how families can protect their loved ones. Without proper notices, families cannot appeal inappropriate discharges or transfers. They also lose access to ombudsman services designed to help resolve disputes.
Federal law requires the written notices to include specific contact information for appeals. Families must receive the name, mailing address, email address, and telephone number of the entity that handles appeals. They also need information on how to obtain appeal forms and assistance completing them.
The notices must include contact information for the state ombudsman office. For residents with intellectual and developmental disabilities, facilities must provide contact information for the state's protection and advocacy agency. For residents with mental disorders, they must include contact information for the agency responsible for advocacy for individuals with mental illness.
Village Healthcare provided none of this information in writing.
The facility's approach violated multiple federal requirements. Nursing homes must notify residents and their representatives "in writing and in a language and manner they understand." Phone calls alone don't meet this standard.
Facilities must also record the reasons for transfer or discharge in residents' medical records. The inspection found the facility was moving residents without following its own documented policies for these transfers.
The Director of Nursing's statement that written notices were "not part of the facility's process or policy" directly contradicts the facility's written Transfer and Discharge Policy. That policy acknowledges federal requirements for documentation, notice before transfer, and orientation for transfer and discharge.
The policy defines facility-initiated transfers as moves "which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences."
Without proper notices, residents and families cannot determine whether transfers align with care goals or preferences. They cannot exercise appeal rights they may not even know they have.
The inspection found the facility was discharging and transferring "some" residents without proper notifications. The exact number of affected residents was not specified in the inspection report.
Village Healthcare's failure to provide written notices left families in the dark about their rights and options when their loved ones were moved. The facility's own nursing staff acknowledged they weren't following federal requirements that protect residents and families during one of the most stressful experiences in long-term care.
The inspection was conducted in response to a complaint. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village Healthcare and Rehabilitation from 2025-11-05 including all violations, facility responses, and corrective action plans.
Additional Resources
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