Failure to Provide Bed-Hold Notice at Hospital Transfer: The facility did not provide the required written bed-hold notice when three residents were transferred to the hospital. Records showed one resident had a broken leg, anxiety, and vision loss with impaired cognition; another had metabolic encephalopathy, kidney disease, and severe cognitive impairment; and a third had respiratory failure, diabetes, and heart failure with intact cognition. Transfer records and interviews with two representatives confirmed the notices were not received, and the DON stated the process was not followed.
Failure to provide bed hold notices and Ombudsman transfer notifications: The facility did not document offering bed hold rights to two residents after hospital transfer, and did not document written notification to the State LTC Ombudsman for two residents transferred to the hospital. The residents had moderate cognitive impairment, and transfers were made for changes in behavior, lethargy, and unresponsiveness.
A resident with obesity, a T-11 to T-12 SCI, multiple rib fractures, and a dislocated elbow was discharged to another SNF, but the facility did not provide recent information about a non-injury fall and an abuse-related sexual behavior allegation. Staff acknowledged no verbal report was given before discharge, and the receiving facility reported the resident arrived without authorization, report, or orders.
Failure to Provide Bed Hold and Transfer/Discharge Notices: The facility did not document providing bed hold notices for four residents who were transferred or discharged to the hospital, including one resident who was unresponsive at transfer. The facility also did not document a written transfer/discharge notice for one resident. Staff interviews and record review confirmed the notices were not found in the EHR, despite facility policy requiring written notice of bed-hold rights and appeal rights when a resident is transferred or discharged.
Failure to Provide Written Discharge Notice and Discharge Planning: A resident admitted for rehab after sepsis, falls, gait impairment, and confusion had no documented discharge plan or discharge goals in the care plan. Although skilled coverage ended and the resident appealed the termination, staff stated they usually notified residents verbally and the EHR did not contain a completed written transfer/discharge notice with appeal rights. The resident’s rep said they were rushed to find an AFH and felt the resident was not ready to leave.
Failure to Provide Written Transfer/Discharge and Bed-Hold Notices: The facility did not provide written transfer/discharge and bed-hold notices for two residents reviewed. One resident’s guardian reported not receiving the discharge evaluation for review and signature, and another resident, who was severely cognitively impaired and had a guardian, was sent to the hospital with the notice completed in the chart but with no documentation that the guardian was contacted or given a written copy.
Failure to provide transfer notifications and hospital reports for two residents. The DON confirmed the facility did not give written notices for hospitalizations, and one resident with respiratory disease and anxiety had multiple hospital transfers with no written transfer notice or report sent to the receiving hospital. Another resident with failure to thrive and spinal narrowing also had a hospital transfer without documentation that the resident or representative received the required written notice.
The facility failed to provide a written bed-hold notice to two residents at the time of hospital transfer. One resident was cognitively intact and said the facility did not discuss holding the bed after transfer for arm surgery, and the EHR had no documentation of a bed-hold notice or contact with the resident or rep. Another resident, who was alert and oriented, was transferred for vomiting, but the EHR also lacked documentation that the bed-hold policy was reviewed before or after transfer.
A resident who left AMA did not have a discharge summary with a recap of the stay or medication reconciliation, and the DON stated life-sustaining meds and a recap should have been provided. Another resident transferred to the hospital during a health emergency had no documentation that a bed hold was offered to the resident or the representative, and the DON confirmed the offer was not made.
A facility failed to provide written transfer/discharge notices, bed-hold notices, and Ombudsman notifications for four residents transferred or discharged to the hospital. Records showed no completed transfer/discharge forms or bed-hold offers for residents with conditions including COPD, HF, pneumonia, and respiratory failure, and one resident reported not receiving a bed-hold notice or returning to the same room after hospitalization.
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.