A resident with dementia, aphasia, and depression was found to have an unplanned discharge after eloping from the facility, but the record lacked documented written notice to the resident and RP, timely ombudsman notification, and evidence of assistance with post-discharge care. The RP had asked about transfer to a SNF closer to home, and staff documented discussion of the transfer process, but there was no clear documented follow-up or discharge notice after the resident left and was later confirmed to be at the RP’s home.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notifications: The facility did not provide written transfer/discharge notices or bed-hold information to resident representatives and did not notify the Ombudsman for three residents who were hospitalized. One resident had intact cognition and was transferred for lethargy and hypotension, while two residents had severely impaired cognition and were transferred for possible stroke and respiratory failure. Records showed only verbal or phone notification in some cases, with no documented written notice or Ombudsman notification.
Surveyors determined that the facility did not send the required transfer notice to the State LTC Ombudsman when a resident with vascular dementia, post-stroke sequelae, constipation, and atrial fibrillation—who had documented memory impairment, behavioral symptoms, and dependence for toileting and transfers—was sent to the hospital via ambulance. A nursing note recorded the transfer, but there was no documentation that the Ombudsman was notified. During interviews, the Director of Social Services and the Assistant Administrator stated that Ombudsman notifications for hospitalizations and discharges were usually emailed in batches and acknowledged that no email notification for this transfer could be located, characterizing the omission as an oversight.
Missing Ombudsman Notifications and Bed Hold Policy Notices: The facility did not document sending transfer/discharge notices to the State LTC Ombudsman for several residents who were sent to the hospital, and it did not provide bed hold policy notices to resident representatives when residents were transferred or hospitalized. A resident with dementia and psychotic disturbance, a resident with dementia, HTN, and DM, and another resident with dementia, BPH, and HTN were all transferred without documented Ombudsman notification or bed hold policy notice; another hospitalized resident also did not receive a bed hold policy notice.
The facility did not complete or send required transfer/discharge notices to residents, their representatives, or the Ombudsman for three residents who left the facility. One resident was sent to the hospital by EMS for abdominal pain and distention, another discharged AMA after a family discussion, and a third was taken to the hospital after a reported fall and hip refracture. An Ombudsman email confirmed missing discharge notifications, and an AA stated the notices had not been sent because there was no Social Worker.
Surveyors found that the facility did not send required copies of transfer/discharge notices to the State LTC Ombudsman for two residents who were transferred to the hospital, one with a hip fracture and dementia and another with dementia and breast cancer experiencing uncontrolled pain and later hospice planning. Although transfer/discharge forms and bed-hold documents were completed and kept in a binder, the Director of Social Work acknowledged that no copies or monthly transfer/discharge lists had been sent to the Ombudsman for several months, and the Ombudsman confirmed not receiving notices or monthly lists during that period.
A resident with kidney failure, DM, metabolic encephalopathy, and borderline personality disorder was discharged to the community with family, but the facility did not document sending the discharge notice to the LTC Ombudsman as required by policy. The SW and DON both stated a copy should have been sent, but no proof could be found in the resident record.
The facility failed to follow required transfer/discharge procedures for three residents with dementia, bipolar disorder, depression, anxiety, and polyneuropathy by not providing timely, complete written notices to them, their representatives, and the State LTC Ombudsman. One cognitively intact resident with dementia and diabetes was moved to a locked unit without documented wandering assessments, without a completed discharge plan, and without a signed notice or timely notification to the representative. Another cognitively intact resident with dementia and bipolar disorder was discharged with a notice dated one day before discharge and no resident signature. A third resident with moderate cognitive impairment reported staff packed and moved them without prior notice; documentation showed a late-entry note stating the resident was notified and given discharge paperwork upon discharge, and the discharge notice used "verbal consent" instead of the resident’s signature. The Ombudsman reported not receiving discharge notices for these moves and stated the facility had been using outdated forms that did not meet current regulatory requirements, while the Administrator acknowledged only issuing 30-day notices when residents were discontent with leaving.
Failure to Notify Ombudsman of Resident Transfer: A resident with severe cognitive impairment, dementia, and dependence for mobility and transfers sustained a fall, was found in pain, and was transferred to the hospital after x-rays showed a left hip fracture. The facility did not send the required transfer/discharge notice to the Office of the State LTC Ombudsman, and the DOSS and Administrator confirmed the notice was not sent.
A resident with significant care needs was discharged without all necessary information being sent to the home care agency, resulting in a delay in the initiation of home care services. The facility did not provide required documentation such as demographics and orders, causing the agency to be unable to process and start services as expected.
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.