A resident with stroke-related deficits, AFib, CVA, and hemiparesis was sent to the ED for possible infection and later found stable to return, but facility leadership refused readmission. Hospital staff and the resident reported the resident wanted to come back, while the Administrator, DON, and Corporate Nurse gave conflicting explanations tied to a bed hold form, alleged behavior issues, and money owed. The resident also reported being yelled at and pressured during hospital meetings about returning.
A resident with bipolar disorder, psychosis, depression, DM2, anxiety, memory loss, and fall risk was discharged to independent living despite staff concerns that she was confused, unsteady, and needed cues, supervision, and medication assistance. Interviews showed she could not manage meds or ADLs safely, did not have needed DME or outside supports in place, and was found after discharge unable to identify herself or her apartment, with meds scattered in the unit and no evidence she was taking the facility-provided meds.
A resident with schizophrenia, psychosis, postpartum medical issues, and a State Guardian was allowed to leave AMA after insisting on discharge. Staff documented that risks were explained, but the guardian was not contacted before departure, the primary MD was not called, and no meds or prescriptions were provided. The AMA form was signed by the resident and a facility witness, while the guardian later stated she was notified only after the resident had already left and had no way to locate her.
A resident with intact cognition, ADL assistance needs, walker use, and therapy referrals was discharged without the facility verifying the placement or arranging needed services. The resident later reported that the new facility in Texas had not received his medical records and was requesting x-ray images, while the DON and Administrator stated they were unsure whether the address had been verified or orthopedic services had been coordinated.
A resident with dementia, acute kidney failure, DM2, and other chronic conditions was discharged despite abnormal labs showing elevated BUN, creatinine, and low eGFR consistent with dehydration. The DON could not verify the results were communicated to the MD, the MD said he was unaware of the abnormal labs and the resident’s hospital return, and the receiving HHA reported the resident was readmitted shortly after discharge with acute metabolic encephalopathy likely related to dementia, dehydration, and UTI.
The facility failed to properly communicate and document the reasons for a resident’s transfer/discharge and then refused to readmit the resident after hospitalization. The resident had dementia, prior strokes, dysphagia, and escalating aggression, but the record showed conflicting accounts between the DON/ADM, hospital CM, and POA about whether the transfer was temporary, whether the resident could return, and whether the family was notified. The hospital documented that the facility later said the room was unavailable and would not coordinate the resident’s return, despite earlier planning for the resident to go back after medical clearance.
A resident’s requested transfer was delayed because the facility did not timely provide documentation the receiving facility wanted regarding C. Auris status. The resident said she kept calling the outside facility and was told the transfer was on hold pending proof she was not contagious. The SS director did not review the ID note stating the resident was safe for discharge from an infectious disease standpoint, did not document follow-up after the discharge summary, and relied on the ADON’s information instead.
A resident with multiple cardiac and musculoskeletal conditions, recently post-CABG and receiving subacute rehab, was discharged home with documented plans and NP recommendations for continued home health PT, OT, nursing, and a bath aide. Social services documented that in-home services would be arranged through a local home health agency, but the discharge instructions given to the resident stated that no services were contacted and did not list any home health provider. After discharge, the resident and family waited for home health that never arrived and later learned from the home health intake coordinator that no referral had been received from the facility; services were only started after the family contacted the agency and orders were obtained from the physician’s office. This sequence of events shows the facility failed to implement the planned home health referral and did not ensure that post-discharge services were actually arranged.
A resident who engaged in self-harm was sent to a hospital behavioral unit, and on the same day the facility issued an involuntary discharge notice stating the resident’s needs and welfare could not be met and that safety was endangered. The hospital psychiatric NP later documented that the resident was A&O x4, denied SI/HI, expressed remorse, was on low suicide precautions, and only required routine psychiatric follow-up and medication monitoring, and reported that the facility declined to readmit the resident despite her being cleared for discharge. The Administrator and a general NP expressed concerns about supervision and lack of onsite psychiatry, but the facility did not perform or document any clinical or psychosocial assessment of the resident between transfer and the proposed return, nor did it document specific needs that could not be met, contrary to its own involuntary discharge policy.
A resident with a history of stroke, aphasia, hemiplegia, seizure disorder, and significant communication and cognitive impairments, whose preferred language was Vietnamese and who required an interpreter, was transferred from the unit to a local county hospital ED without written notice of transfer/discharge to the resident or the state guardian. Staff had long known the resident had no insurance, no family, and a state guardian, and that prior placement attempts had failed due to financial and identity issues. As the unit prepared to close, staff contacted a hospital transfer center, which declined admission for lack of acute need, yet the facility still arranged a private ambulance transfer to the ED based on reported verbal direction from county officials, without documented discharge planning, referrals, a discharge care plan, or a written notice specifying the reason, effective date, and destination of the transfer.
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.