Fidelity Health Care

bed-hold policies.

interview and record review, the facility failed to complete a Notice of Proposed Transfer/Discharge

with issues related to day-to-day care, health, safety, and personal preferences) of a transfer for one of three sampled residents (Resident 1), when Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 2/24/2026.This deficient practice placed Resident 1 at risk for an inappropriate and unsafe discharge and violated Resident 1's rights.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome (pain that lasts longer than three months).During a review of Resident 1's History and Physical (H&P), dated 8/25/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 1 had intact cognition (ability to understand).

The MDS indicated Resident 1 was independent with daily activities and mobility.During a review of Resident 1's Physician Order (PO), dated 2/24/2026, the PO indicated to transfer Resident 1 to another General Acute Care Hospital (GACH) via paramedic (a highly trained healthcare professional who provides emergency medical care and transportation).During a review of Resident 1's Progress Notes (PN), dated 2/24/2026 and timed at 8:50 PM, the PN indicated Resident 1 was transferred to the GACH 1 via paramedic for pain.During an interview on 2/26/2026 at 2:50 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the licensed nurse who discharged Resident 1 should have completed an NPTD during Resident 1's transfer process.During a concurrent interview and record review on 2/26/2026 at 3:31 PM with the Director of Nursing (DON), Resident 1's medical records were reviewed.

The DON was unable to find an NPTD for Resident 1's hospital transfer on 2/24/2026.

The DON stated the facility should have completed the NPTD for Resident 1's transfer on 2/24/2026.

The DON stated the NPTD must be completed and kept in Resident 1's medical record.

During an interview on 2/27/2026 at 12:38 PM with Registered Nurse 1 (RN 1), RN 1 stated the licensed nurse should have completed the NPTD upon transferring the resident to GACH 1. RN 1 stated the purpose of the NPTD was to inform the resident where the resident would be transferred to and the reason for the transfer. RN 1 stated it was the facility's practice to place the NPTD in the resident's medical record as proof the NPTD was completed.During a review of the facility's Policy & Procedure (P&P) titled Proposed Transfer and Discharge Notice, dated 1/2004, the P&P indicated, A written notice was to be provided to the resident and, if known, a family member or resident's personal representative, of the reasons for the transfer or discharge as soon as practicable before the transfer or discharge takes place.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE