Failure to provide complete written transfer and bed-hold notices affected three residents who were sent out for hospitalization. For each resident, the facility documented notices as verbal or incomplete, and the transfer notices did not include the reason for transfer and/or the location of transfer. One resident had a GI bleed, another was sent out after vomiting and fever with a UTI history, and a third was hospitalized for hypoglycemia, acute encephalopathy, increased troponin, and syncope.
Incomplete bed-hold notices were provided for multiple residents after hospital transfers, with required details missing such as the reason for transfer, the receiving location, appeal rights, Ombudsman contact information, and advocacy resources. One resident with DM2, a BIMS score of 15, and recent hospital transfers also received bed-hold notices that lacked the reason for transfer and financial assistance resources. Staff interviews confirmed the forms were often completed verbally and sent with the resident, while the DON stated the notices should include all required information.
A facility failed to provide written transfer notices with the specific reason for hospital transfer for several residents. Records for residents with conditions including dementia, GERD, diabetes, and a ventral hernia showed only a generic statement that the transfer was necessary for the resident’s welfare, while the actual reasons included falls with pain, choking, mental status change, abdominal pain with suspected GI bleed, nausea/vomiting with possible bowel obstruction, and a persistent bloody nose. Staff interviews confirmed the transfer notice was expected to document the reason for the transfer.
A resident was transferred to the hospital, but the facility did not complete or keep the required written bed-hold notice for the resident and/or resident representative. The facility policy required written notice at transfer explaining bed-hold duration, reserve bed payment policy, return-to-bed conditions, and a signed copy in the chart. The ADON confirmed the facility did not have a bed hold for the hospital admission but should have had one.
Missing transfer, bed-hold, and Ombudsman notifications: The facility did not document required transfer/discharge notices or bed-hold information for several residents who were discharged home or sent to the hospital, including residents with hospice care, POAHC involvement, and repeated hospital transfers. The NHA stated the Business Office was not completing Ombudsman notifications, and the facility could not produce evidence that the Ombudsman was notified or that the required notices were provided.
Written bed hold notices were not completed for four residents who were transferred or hospitalized. Records for the residents did not contain the required bed hold documentation, and the DON/CNO and NHA confirmed there were no bed holds for those transfers. A SW stated the notice should accompany the transfer paperwork and a copy should remain in the resident record.
Failure to notify the Ombudsman of resident transfers: two residents were transferred to the hospital multiple times, but their names were not included on the monthly discharge list sent by the SW. The SW said the report only captured residents discharged to home and did not know hospital transfers also had to be included; the NHA confirmed the same guidance had been provided.
A resident was transferred to the ED twice for a change in condition, but the facility did not include either transfer in its monthly Ombudsman notification process. During survey review, the SW provided discharge notification logs, and the resident’s ED transfers were not listed. The SW stated they were not aware the notification requirement included ED transfers, and the facility policy did not address Ombudsman notification requirements.
Failure to notify the Ombudsman of resident hospital transfers. The facility did not include several residents on monthly transfer notices, and records showed multiple hospital transfers with no documentation that the Ombudsman was informed. An SW stated the submitted lists were accurate but could not locate the residents on the documentation.
Failure to Provide Written Transfer Notices: The facility did not provide written transfer notices for multiple residents who were sent to the hospital. Records showed hospital transfers and, in some cases, signed bed hold notices or Ombudsman notification, but no written notice with the reason for transfer, Ombudsman contact information, or appeal rights. The DON and medical records staff stated they were unaware the notice was required for residents or next of kin.
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.