§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
§483.15(d) Notice of bed-hold policy and return-
§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.
§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
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Observations:
Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for three of six hospitalizations reviewed (Resident 1, 6, 11) and one of three closed records reviewed (Resident CR75), and failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of three closed records reviewed (Resident CR8).
Findings include:
Review of Resident 1's clinical record revealed a nursing progress note dated December 12, 2025, indicated the resident was transferred to the local hospital for evaluation.
Review of documentation provided by the Nursing Home Administrator on February 26, 2026, revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident 1's facility-initiated emergency transfers to the hospital.
Interview conducted February 26, 2026, at 11:54 a.m. with Employee E4, confirmed that the office of the state long-term ombudsman was not made aware of Resident 1's hospital transfer.
Review of Resident 6's clinical record revealed a nursing progress note dated January 17, 2026, indicating that the resident was transferred to the hospital for evaluation.
Review of documentation provided by the Nursing Home Administrator on February 26, 2026, revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident 6's facility-initiated emergency transfers to the hospital.
Interview conducted February 26, 2026, at 11:54 a.m. with Employee E4, confirmed the ombudsman was not made aware of Resident 6's hospital transfer.
Review of Resident 11's clinical record revealed Resident 11 was discharged to the hospital on January 1, 2026, and re-admitted to the facility on January 6, 2026.
Further review of Resident 11's clinical record failed to reveal evidence that the office of the State Ombudsman was notified of Resident 11's admission to the hospital.
Interview with the Director of Nursing on February 26, 2026, at 11:00 a.m. confirmed that the office of the State Ombudsman was not notified of Resident 11's transfer to the hospital.
Review of Resident CR8's clinical record revealed a nursing progress note dated February 10, 2026, at 10:46 a.m. indicated the resident was discharged from the facility to their home.
Review of Resident CR8's Minimum Data Set dated February 10, 2026, indicated the discharge was planned.
Interview conducted with the Nursing Home Administrator (NHA) on February 27, 2026, at 1:15 p.m. reported that the facility did not complete a discharge summary, including a recapitulation of the resident's stay for Resident CR8. The NHA also confirmed that the facility did not notify the Office of the State Long-Term Care Ombudsman of Resident 1's or Resident CR75's transfer to a hospital.
Review of Resident CR75's clinical record revealed a nursing progress note dated February 2, 2025, indicated the resident was admitted to a local hospital for evaluation.
Review of Resident CR75's Minimum Data Set (a standardized assessment tool used in Skilled Nursing Facilities to evaluate resident health, guide care planning, and support Medicare and Medicaid reimbursement) dated February 2, 2026, revealed the resident was transferred to a nearby hospital and subsequently discharged from the facility on the same day.
Interview conducted February 26, 2026, at 11:54 a.m. with the Social Services Department, confirmed the ombudsman was not made aware of Resident CR75's hospital transfer.
28 Pa. Code 201.14(a) Responsibility of licensee
| | Plan of Correction - To be completed: 04/01/2026
1. The Facility Ombudsman was notified of Residents 1, 6, 11 and CR75 discharge from the facility.
2. The Social Services Director or designee will audit current residents who discharged in the last 30 days to ensure that notification of discharge from the Facility was provided to the Ombudsman.
3. The Social Services Director will be re-educated by the NHA on the importance of completing notification of discharge from the Facility to the Ombudsman.
4. The NHA and/or designee will audit current residents and new admissions who have discharged from the facility for notification provided to the Ombudsman four weeks and then monthly for a period of two months. Audits and compliance will be reviewed monthly at the facility's Quality Assurance and Performance Improvement meeting.
5. Facility Date of Compliance will be 4/1/2026.
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