A resident with a BIMS score of 12/15 had an urgent hospital transfer after a change in condition, but the facility’s proposed transfer/discharge notice did not include the appeal process or the agency handling appeals. The SSD said she was unsure which agency handled appeals and was unaware the form lacked this information, and the MDSC stated she was unsure of the process.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
Failure to Provide Written Transfer Notice and Bed-Hold Information: The facility did not ensure that a resident with dementia, psychosis, and severe cognitive impairment, or the resident’s RP, received a written notice of transfer or a bed-hold notice when the resident was transferred to the hospital for ongoing behavioral disturbances and psychosis. Record review found no evidence of either notice, and the Administrator stated there was no bed-hold policy or written transfer notice provided to the RP.
The facility failed to send discharge notices to a representative of the State LTC Ombudsman for two residents. One resident had moderate cognitive impairment and an active discharge plan to return to the community, while another was transferred to a hospital for a change in medical condition. The DSS stated she was responsible for the notifications but had not sent either discharge notice, and the Ombudsman reported not receiving resident discharge notices from the facility since 05/25.
Failure to Provide Bed Hold Policy Notification: A resident was transferred to the hospital by EMS and did not return, but the record lacked documentation that the required written bed hold notice, including reserve bed payment requirements, was given to the resident or representative at transfer, sent with transfer paperwork, or provided within 24 hours. The SSW and Administrator both confirmed they could not locate evidence that the notice had been provided.
A resident with a history of respiratory failure, who had been receiving supplemental O2 in the facility, was discharged home without discharge paperwork or supplemental O2. The responsible party had informed staff in advance of the planned discharge and was told paperwork would be ready, but when they arrived, no discharge documents were available and attempts by nursing staff to obtain them were unsuccessful. The resident left without discharge instructions, and the SW later confirmed that although the resident had received supplemental O2 in the facility, no O2 order was sent home. Discharge instructions were instead reviewed with the responsible party by phone several days after the resident had already left.
Incomplete Bed-Hold Notice After Hospital Transfer: The facility failed to provide a completed bed-hold form to a resident’s responsible party within a practicable amount of time after hospital transfer. A blank bed-hold notice was mailed, and there was no documentation that the corrected amount was sent before the resident returned. The Admissions Coordinator said the omission was an oversight, and the DON stated the bed-hold information should be mailed timely to the resident representative.
The facility failed to send the required transfer/discharge notice to the LTC Ombudsman for one resident who left AMA. Records showed the resident signed an AMA release with two staff witnesses, but the discharge was not included on the facility’s notice spreadsheet sent to the ombudsman. The admission director stated she was unaware the notification had to be sent and said it was not done.
The facility did not notify the Ombudsman of the discharge of two residents who were transferred to a hospital for care that could not be provided at the facility. Although internal procedures assigned responsibility for notification to the Social Worker, the Ombudsman's office reported not receiving any transfer or discharge reports from the facility for several months.
A resident and their representative were not given a written bed hold notice that included the required current per diem rate when the resident was transferred to a hospital. Although the bed hold policy and rate changes were reviewed at admission and mailed to representatives, the specific rate was not included on the notice at the time of transfer, leaving the resident without all necessary information.
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