The facility failed to provide required written notification to the LTCO for six residents who were transferred from the facility, including five discharged home and one transferred to another facility, as shown by review of the admission/discharge report. A social services staff member stated she only notifies the LTCO when a resident is transferred to a hospital and had not notified the LTCO for residents going home or to another facility, while an administrative staff member stated she expected all transfers to be reported to the ombudsman. The facility could not produce a policy addressing LTCO notification for residents transferred to another facility or discharged home.
Two residents with dementia and other comorbidities were transferred to the hospital for acute conditions such as hip fracture, pneumonia, shortness of breath, chest pain, hypotension, and brief unresponsiveness, but the facility failed to provide required written notifications of transfer, reasons for transfer, and bed-hold rights to the residents and/or their representatives, and did not send copies to the ombudsman as required. Documentation in the EHR lacked evidence of bed-hold notices, and staff interviews revealed confusion about who was responsible for issuing and obtaining signatures on bed-hold forms, with one staff member describing a practice of completing and signing bed-hold forms after the resident’s return or mailing them days later. This practice conflicted with the facility’s own bed-hold policy, which required written notice at admission and at the time of transfer, and administrative staff acknowledged that the facility did not provide written discharge or transfer notices and did not have a discharge policy.
A resident with anemia, CKD, DM, HTN, and major depressive disorder, who required extensive ADL assistance and used a wheelchair, was sent to the hospital after a critical Hgb result and provider direction to transfer. The record showed no written bed-hold notice or documentation of the facility’s bed-hold policy for this facility-initiated transfer, and staff confirmed that no such notice was given. The facility also lacked evidence that the State LTCO was notified of the resident’s transfer/discharge, and could not produce an Ombudsman notification policy, despite a written bed-hold policy requiring resident notification and filing of the bed-hold information in the medical record.
A resident was transferred to an acute hospital without receiving the required written notice detailing where and why the transfer occurred, their appeal rights, and state ombudsman contact information. The Nursing Home to Hospital Transfer Form lacked the transfer location, documentation that the resident or representative was notified, and the reason for transfer, as well as any statement of appeal rights or ombudsman details. Staff reported relying on EMR documentation and stated that written notices were not provided when a resident was their own legal representative or had an intact BIMS score, and the facility’s policy referenced written notice but did not ensure these elements were included for this unplanned hospital transfer.
A resident with obesity, O2 dependence, cognitive communication deficit, and skin cancer experienced respiratory symptoms and was transferred to the hospital after nursing staff documented shortness of breath, productive cough, and low O2 saturation, with a phone message left for the responsible party. Although the EMR showed a bed-hold assessment with verbal confirmation and the resident later returned for skilled therapy, there was no written notice explaining the reason for transfer provided to the resident or representative, nor was a copy sent to the ombudsman. Interviews with the resident, social services, and an administrative nurse revealed that staff were unaware or unsure of written notification requirements and that the facility had not been consistently issuing written transfer notices or ombudsman notifications, contrary to its own transfer/discharge policy requiring detailed written notice and appeal information.
Surveyors found that the facility did not provide required written notifications of transfer or notify the LTCO when three residents were transferred to the hospital, including one who later returned and two who did not. Staff reported that they notified representatives of hospital transfers by phone and documented progress notes, but did not complete written transfer notices and were unfamiliar with this requirement. Review of LTCO discharge notification emails over a one-year period showed that these hospital transfers were not reported. The facility’s policy required written notice with reasons, effective date, receiving location, LTCO and State Agency contacts, and appeal rights, but did not specifically address written notification or LTCO reporting for hospital transfers.
Surveyors determined that the facility failed to provide required written notification of transfers for three residents who were sent to the hospital for issues including vomiting with pain, evaluation and treatment ordered by a provider, and hallucinations reported by family. In each case, documentation showed that the residents were transferred via EMS or at a family member’s request, but the EMR contained no evidence that written transfer notices were given to the residents or their representatives. Staff reported that they sent bed-hold information with the transfer packet and notified families by phone, but they were not aware of the requirement for written transfer notification, despite a facility policy stating that facility-initiated discharges require resident or representative notification and documentation.
A resident with DM, major depressive disorder, and a developmental disorder was hospitalized, and staff obtained a verbal bed-hold consent from the resident’s DPOA but did not provide or document provision of a written bed-hold policy including duration. Nursing staff reported they only obtained verbal bed holds and did not send forms with residents to the hospital, while administrative staff stated they completed the bed hold verbally and intended to mail the form but kept no record of doing so. The social services designee documented only verbal consent and was unaware that a paper copy had to be given, and another administrator confirmed there was no system to verify that a written bed-hold notice was provided when consent was obtained verbally, despite existing instructions requiring documentation of how the form would be delivered.
A resident with dementia, acute blood loss anemia, and a lower GI bleed, who required partial staff assistance with ADLs and had moderately impaired cognition per MDS BIMS, was admitted for care and later discharged home with a spouse. The care plan identified discharge as an outcome and directed staff to support the resident and family through care plan conferences, discharge planning, and discussion of alternative care options. Despite this, the clinical record did not contain a recapitulation summarizing the resident’s stay and course of treatment at discharge, and facility leadership confirmed that this required discharge documentation was not completed, contrary to the facility’s discharge planning policy.
A resident with schizoaffective disorder and borderline intellectual functioning, who had intact cognition and verbal behaviors toward others, was issued an involuntary discharge notice after behaviors that allegedly endangered others, including actions posing a serious fire risk. The facility did not develop a comprehensive care plan, did not obtain a physician discharge order, and did not complete a discharge summary with a recapitulation of the stay or documented medication reconciliation, even though the resident was discharged home with medications. The involuntary discharge notice omitted required elements, including instructions on how to file an appeal, identification of who at the facility would assist with an appeal, the Ombudsman’s name and email, and contact information for state protection and advocacy agencies for individuals with developmental disabilities and mental disorders.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account