The facility failed to complete and document discharge planning for two residents. One resident's record did not clearly document the discharge reason, the discharge location was inconsistent across records, and the EMR did not show the reconciled med list and care plan as part of the discharge documentation. For the other resident, the care plan was not updated to reflect a preference to transfer to another SNF, and the EMR lacked documentation of discharge preparation in a form the resident could understand.
The facility failed to provide and document written bed hold notices for two residents when they were transferred to the hospital. One resident had acute kidney failure and CHF and was cognitively intact, and another had acute and chronic respiratory failure, pulmonary hypertension, and a respiratory virus with intact cognition and wheelchair dependence. Records did not show completed bed hold forms, and staff stated the forms were not provided at transfer.
Failure to provide written bed-hold notice at hospital transfer: A resident with COPD, asthma, URI, and RSV was sent to the hospital for low O2 sat, cough, SOB, and respiratory distress, but the EMR had no documentation that she or her RP received the required bed-hold notice. RN said she did not know a bed-hold form was needed, and the SSD said she did not complete the form or notify the facility’s frequent visitor.
Incomplete hospital transfer documentation: A resident with CVA history, AFib, hyperlipidemia, and severe cognitive impairment was sent to the hospital after new right-sided weakness was noted. Although staff documented the ambulance transfer and family involvement, the EMR did not show that transfer information was provided to the hospital and the discharge summary was not completed at the time of transfer. The DON and an RN stated that a transfer form and related documentation should be completed and sent whenever a resident leaves the facility.
Failure to Notify Ombudsman in Writing Before Discharge: A resident with a recent lower-leg fracture, asthma, DM2, and fibromyalgia was discharged after a skilled rehab stay, and staff assisted with an appeal after the insurer stopped covering services. However, the SSD only left a voicemail to the LTC ombudsman and did not document written notification before discharge, and the EMR lacked evidence that the ombudsman was notified in writing.
Failure to Document and Notify for Facility-Initiated Discharge: A resident with subdural hemorrhage, falls, cognitive impairment, and mobility deficits was sent to the ED after elopement and combative behavior, then the facility refused readmission. The EMR did not document the discharge process or reason, and the resident/rep was not given written discharge notice with the reason, effective date, discharge location, appeal rights, or LTC ombudsman contact info; timely ombudsman notification was also not documented.
A resident with Parkinson's disease, COPD, dysphagia, and HTN was sent to the hospital after a fall with head injury, but the facility did not document that the resident or representative received the required bed hold policy at the time of transfer. Although a signed form was later produced, the date on it matched the resident’s original admission rather than the hospital transfer, and staff confirmed the sending nurse was responsible for providing the notice.
A resident with COPD, encephalopathy, and depression had a discharge goal that changed from community placement with family to LTC, but the discharge care plan was not updated to reflect the new plan. The resident later left AMA after being found at a hotel, and the record did not show written notification to the ombudsman or notification to the physician.
A resident with multiple medical conditions left the facility against medical advice due to dissatisfaction with care and environment. The facility did not document physician notification regarding the discharge request or the actual AMA discharge, nor did staff document attempts to address the resident's concerns or discuss alternative discharge plans. Required AMA discharge procedures and documentation were not followed.
A resident with multiple complex medical conditions was discharged without a documented assessment or arrangement for home oxygen therapy and timely home health services for intravenous antibiotics. The care plans and discharge summary indicated ongoing needs, but the facility did not confirm or document referrals for necessary equipment or services, resulting in a delay of home health care and missed medication doses.
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 August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.