A resident with severe dementia and significant behavioral disturbances, including wandering, disrobing, inappropriate urination/defecation, and sexually inappropriate and aggressive behaviors toward others, was involved in a serious incident where he exposed himself, assaulted an LPN, and entered a female resident’s room naked, causing her to fall while trying to escape. Both residents were sent to the ER, and the administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others. However, surveyors found no documentation in the electronic health record of the immediate discharge, no record that the resident’s spouse was informed of the discharge and its reasons, and no scanned discharge notice. A separate paper folder contained a discharge notice inaccurately listing the discharge destination as the family home and notes about notifying the receiving facility and spouse, but the administrator confirmed this information was never entered into the electronic record, contrary to the facility’s discharge/transfer policy.
A resident with multiple chronic conditions and moderate cognitive impairment was discharged home without the facility involving her POA in the discharge planning process, despite documentation that the POA had previously provided input favoring long-term placement and a care plan intervention for social services to meet with both resident and family to determine the discharge plan. The resident met with a PA, signed a discharge packet with medication and home health orders, and was picked up by family on the day of discharge, but there was no documented consultation or prior notification to the POA. The DON acknowledged that the family was not included in the discharge discussion, which conflicted with the facility’s discharge planning policy requiring collaborative planning and documentation of resident and representative notification.
A resident with multiple chronic conditions, who was assessed as cognitively intact, was discharged without any documentation in the medical record of their discharge disposition, recapitulation of stay, or discharge arrangements. The record lacked a discharge summary, nursing discharge note, and post-discharge plan of care. The DON confirmed these omissions, which were inconsistent with the facility’s own policy requiring nursing to obtain discharge orders, prepare a discharge summary and post-discharge plan, and complete a discharge note prior to discharge.
Unsafe discharge without required notice: A resident with epilepsy, TBI, severe cognitive impairment, and ongoing behavioral symptoms was sent with her husband to an ER after staff-directed aggression escalated. The hospital did not admit her, the facility then refused readmission, and the resident was ultimately taken home. The record showed no discharge notice or appeal rights were provided before the discharge, and the facility’s own policy allowed discharge only under limited circumstances.
A resident with multiple complex conditions and severe cognitive impairment was issued a NOMNC by phone, then transferred to the hospital for elevated heart rate. The transfer form contained only clinical information and lacked evidence of a written transfer/discharge notice. The resident was taken off the census the same day, and after the BFCC-QIO later upheld the end of Medicare coverage, there was no documentation that the resident or representative was offered the option to return or stay on a private-pay basis or informed of service costs. The Administrator confirmed that no bed-hold notice or option to hold the bed was provided, the bed was not held during hospitalization, and the bed was reassigned so no bed was available when the resident was ready to return.
The facility failed to adequately plan and document safe, goal-directed transfers and discharges for two residents. One resident with a history of substance abuse and an established plan to discharge to family was transferred to another nursing facility while intoxicated after a fall, with no clear documentation of why his original discharge plan changed, how the receiving facility was selected, or how it would better meet his needs. Another resident with multiple medical and psychiatric diagnoses, admitted after alcohol detox and scheduled to transfer to a VA inpatient rehab program, was instead discharged home without a physician order, without being processed as an AMA discharge, and without documentation explaining the change from the planned transfer or how her discharge goals and needs were addressed.
A resident with multiple chronic conditions, cognitively intact and dependent for ADLs with tube feeding, was transferred to the hospital, readmitted, and later given a 30‑day discharge notice. Social Services informed the resident’s daughter that there were no remaining bed hold days and that the resident would return as skilled, and later mailed a discharge notice stating the resident’s welfare and needs could no longer be met. The RSC later acknowledged the true basis for the discharge was concern about lack of a payer source and that the form was completed incorrectly. The RBOM confirmed the stay was still covered by managed Medicaid through a specified approval period when the notice was issued and that no bill for non‑payment had been sent, despite facility policy limiting discharge to defined causes such as inability to meet needs or failure to pay.
A resident with dementia, DM2, encephalopathy, and PTSD was sent to a psychiatric hospital after physically assaulting staff and other residents, with the facility’s transfer log indicating an expected return. The facility later decided on an immediate involuntary discharge due to safety concerns but did not notify the resident’s representative in advance, provide written notice, or offer appeal rights. On the day of discharge, the facility transported the resident from the psychiatric hospital to the representative’s home without documented discharge planning, interdisciplinary evaluation, or assessment of the home’s suitability, and the representative, who was already caring for an elderly parent, refused to accept the resident. The facility’s actions did not follow its own discharge planning policy requiring involvement of the resident/representative and ensuring the discharge destination met health, safety needs, and preferences.
A resident admitted for respite care and later discharged with hospice had moderately impaired cognition and required extensive assistance with ADLs and medication administration. The facility failed to complete a discharge plan, failed to include a Discharge Summary, and could not confirm the resident's discharge location, written discharge instructions, or whether the resident's representative was notified; the DON confirmed the missing documentation and unclear discharge details.
A resident with complex medical needs and limited self-care abilities was discharged from the facility to a homeless shelter without adequate notice, preparation, or discharge planning. The resident did not receive necessary diabetic teaching, lacked essential supplies, and was not provided with assistance to secure income or housing. The homeless shelter lacked medical staff and could only provide temporary accommodation, and the resident was unaware of the discharge until the day it occurred. Facility staff did not notify the Ombudsman or provide proper documentation of the discharge process.
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