Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices: The facility did not provide written transfer/discharge notices or bed hold notices to resident representatives for 4 sampled residents transferred to an acute hospital. Records showed the notices were not sent in writing, and the SS Mgr and an LSW confirmed the facility only sent a packet with the resident and notified the Ombudsman.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
Failure to notify the Ombudsman of resident transfers/discharges and to provide a written transfer/discharge notice to a resident and legal representative. One resident was transferred home with services, but the LSW said Ombudsman notifications had not been sent for any transfers or discharges. Another resident was transferred to the hospital for respiratory distress, and the record showed no written notice was given to the resident or representative; the DON confirmed the notice was not provided.
Two residents were transferred multiple times to acute care hospitals, including ED visits and an admission for an intestinal blockage, without documented written transfer/discharge notices or bed-hold notices, including cost of care, being provided to their legal representatives. Clinical records and nursing notes confirmed the transfers and hospital admissions, but lacked evidence of the required written notifications. The LSW later acknowledged that there was no documentation of these notices and indicated that one ED transfer was viewed as a scheduled appointment, and thus she believed notices were not required.
A resident who experienced a fall with major injury and was transferred to the hospital for evaluation and treatment did not receive the required written bed-hold notice at the time of transfer. Review of the clinical record showed no documentation that the resident or representative was given a bed-hold notice for that hospitalization, and a social worker confirmed during interview that, although other bed-hold notices existed in the record, none corresponded to the date of this specific transfer.
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 June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account