The facility failed to notify the State Ombudsman of resident transfers and discharges and did not provide a written reason for a hospital transfer to a resident or the resident representative. A resident was transferred to the hospital and later returned, but records showed no Ombudsman notifications had been sent for months, and staff confirmed they only called families and did not provide written transfer documentation.
A resident admitted after a right hip fracture was discharged to the family home, but the facility did not notify the Ombudsman of the discharge. Record review showed no evidence of notification, and the Administrator confirmed the facility only notified the Ombudsman for facility-initiated discharges.
The facility failed to notify a resident’s responsible party of the bed hold when the resident was transferred out, and failed to include another resident’s transfer/discharge on the monthly ombudsman report. Record review and staff interview showed the bed hold notice was given to the resident and mailed later to the family, but there was no documentation that the responsible party was notified at the time of transfer. The monthly Action Summary sent to the ombudsman also omitted a resident who was hospitalized and later discharged to another care facility.
Failure to complete recapitulation of stay for a resident admitted with a displaced trimalleolar fracture of the R lower leg and L foot drop. Record review showed no evidence the document was completed before discharge, and the DON stated it was not initiated by social services in the charting system.
A resident was discharged, but the facility did not notify the ombudsman of the discharge. Record review showed the ombudsman notification log only included hospital transfers, and the SSD confirmed the facility did not notify the ombudsman for discharges to home or transfers to another nursing facility.
Failure to Notify Ombudsman of Hospital Transfers: The DON confirmed the facility did not notify the State LTC Ombudsman of multiple hospital transfers for one resident with moderate cognitive impairment and another resident with CHF, AKI, hypotension, anxiety, and SOB. Facility policy required transfer/discharge notices to include the Ombudsman’s contact information, but records showed no notification for the resident’s hospital leave after a fall or for several hospital discharges related to acute heart failure, CHF, renal failure, chest pain, and low BP.
A resident was discharged home with the spouse, and the record showed belongings, discharge instructions, and a medication list were provided. However, there was no documentation of the required summary or recapitulation of stay in the EMHR, and the DON confirmed the discharge summary was not completed.
Failure to notify the ombudsman of two resident discharges. Record review showed two residents were discharged, but a fax from the SSS did not show that either discharge had been reported. The Administrator confirmed the ombudsman was not notified, and the DON stated the facility had no discharge policy and that the nursing discharge checklist did not include duties for departments outside nursing.
The facility failed to complete discharge summaries for two residents who were discharged from the LTC facility. One resident was transferred to the hospital after reporting intolerable abdominal pain and did not return, and another resident was discharged home with home care services. The DON confirmed that no discharge summaries were completed for either resident.
A resident was discharged to a family member's home, but the facility did not complete a recapitulation of stay and did not notify the Ombudsman of the discharge. The DON confirmed the recapitulation was not completed, and the SSD confirmed the Ombudsman was only notified for emergency transfers, not other discharge types.
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 October 8, 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.