Failure to Notify LTC Ombudsman of Transfers/Discharges: The facility did not document or provide required LTC Ombudsman notification for multiple residents who were discharged or transferred, including planned SNF discharges, a discharge home with skilled services, and hospital transfers. Records lacked CMS Form 3120 documentation or showed incomplete forms, and one LTC Ombudsman confirmed no transfer notice was received.
Failure to Notify LTC Ombudsman of Resident Transfers and Discharges: The facility did not provide required transfer/discharge notice or CMS Form 3120 to the LTC Ombudsman's office for four residents who were transferred to acute-care hospitals and later returned. Records for residents with ESRD, neurocognitive disorder, and cancer lacked evidence of Ombudsman notification, and interviews showed the SSD was sending only a monthly log while the Administrator confirmed notifications were not being processed appropriately.
The facility failed to notify the LTC Ombudsman’s office of multiple resident transfers and discharges, including planned discharges and acute care hospital transfers. Records for several residents with diagnoses such as dementia, metabolic encephalopathy, cerebral infarction, acute cholecystitis, and muscle wasting showed no CMS Form 3120 or Ombudsman notification in the EMR. Interviews confirmed the facility was sending only a monthly log, and the discharge planning policy did not address Ombudsman notification.
Failure to Notify LTC Ombudsman of Transfers and Discharges: The facility did not provide required CMS Form 3120 transfer/discharge notices or evidence of LTC Ombudsman notification for multiple residents who were transferred to acute care hospitals or discharged home. Records for residents with diagnoses including fracture, intracranial injury, metabolic encephalopathy, stroke-related hemiplegia, sepsis, CHF, and aortic valve stenosis lacked the required documentation, and staff interviews confirmed the March notices had not been sent until later.
Two residents were transferred to other SNFs without receiving the required 30-day written notice and without clear evidence of consent or proper discharge orders. In one case, a resident was moved the day after receiving notice, the discharge form lacked the resident’s signature, the resident reported never signing any forms and being told abruptly to pack and leave, and record review showed no MD order for discharge. In the other case, a resident’s daughter/POA reported she was told transfer was only a possibility, was not called back before the move, and later learned the resident was already on the bus; she also reported missing belongings and that the resident was unprepared and unaware the move was permanent. Facility leadership acknowledged that same-day notice was used when a resident was considered agreeable and that a verbal MD order for transfer had been given, despite a written policy requiring interdisciplinary discharge planning and prior review of the discharge plan and proposed date with the resident or representative.
Failure to Notify LTC Ombudsman of Resident Transfers and Discharges: The facility did not provide transfer/discharge notices or copies of the actual forms to the LTC Ombudsman for three residents reviewed. One resident was discharged to another facility, one was transferred to an acute care hospital and later discharged home, and one was discharged from the facility; in each case, the EMR lacked the required discharge/transfer form and there was no documented proof that the Ombudsman was notified. The DON/ADON and SSD were unable to verify the process, and the Administrator could not produce fax confirmations showing the notices were sent.
A resident was transferred to a hospital for evaluation and treatment of a right hip concern after the attending practitioner directed staff to send the resident to the closest hospital, and non-emergent transport was arranged with the resident’s family in agreement. Although a transfer/discharge notice and a hospital transfer form were completed, surveyors found no documentation that the required written bed-hold notice—detailing the state bed-hold policy, any reserve bed payment policy, and the facility’s bed-hold and return policies—was provided at or before the time of transfer. In interviews, an LPN/medical records staff member acknowledged that the bed-hold notice “must not have been done,” and the DON stated that floor nurses or unit managers are responsible for completing bed-hold forms and obtaining family signatures when present, confirming that this process was not followed for this hospitalization.
A resident was emergently transferred after aggressive behaviors and an involuntary emergency psychiatric evaluation, but the facility did not send the transfer/discharge notice with the reason for transfer to the Ombudsman. The DON and Administrator gave conflicting explanations about the transfer, and the Ombudsman only received a monthly discharge report that did not identify the psychiatric evaluation reason.
Failure to complete transfer/discharge notices and notify the Ombudsman: Three residents were discharged or transferred, including one sent to an acute care hospital for SOB/respiratory distress and two discharged at the resident or family request. No AHCA 3120-002 notices were found in the records, and there was no indication that the Ombudsman's office was notified. Interviews with the DSS, Administrator, and DON confirmed that no transfer/discharge notifications were sent to the Ombudsman for the month.
Failure to Notify Ombudsman of Resident Transfers and Discharges: The facility did not complete the required transfer/discharge notice forms for four residents, and the Ombudsman office did not receive the actual AHCA 3120-002 forms. The SSD said he faxed a monthly discharge list instead of the forms, while the MDS Coordinator/RN confirmed her department issued resident discharge notices but could not confirm when Ombudsman notification occurred and was unaware the actual forms had to be sent.
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.