§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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, and to ensure that the ombudsman was notified of the transfer to the hospital, for seven of 38 residents reviewed (Residents 1, 4, 7, 12, 76, 100, 144).
Findings include: 2
The facility's policy regarding ombudsman notification, dated May 29, 2026, indicated that the ombudsman would be notified on a monthly basis of any emergent facility initiated discharge or transfer.
The facility did not provide a policy regarding providing a written notice to the resident and the resident's representative upon transfer to the hospital.
A quarterly MDS assessment for Resident 1, dated May 21, 2026, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had a diagnoses that included malignant neoplasm of the bladder.
Nursing notes for Resident 1, dated May 2, 2026, at 4:37 p.m., revealed that the resident presented with an altered mental status and blood in his urine, he was transferred to the hospital and was admitted
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated February 14, 2026, revealed that the resident was cognitively intact, required partial assistance from staff for daily care needs and had medical diagnoses that included dementia.
A nursing note for Resident 4 dated April 2026, at 12:24 pm revealed that the resident was nonverbal and lethargic, and she was sent to the emergency room for evaluation.
Review of Resident 4's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalization on April 20, 2026.
A quarterly MDS for Resident 7 dated January 6, 2026, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.
A nursing note for Resident 7 dated March 5, 2026, at 3:13 p.m. revealed the resident had an unwitnessed fall, was sent to the hospital for evaluation and was admitted.
Review of Resident 7's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalization on March 5,2026.
An admission MDS for Resident 12 dated June 29, 2026, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.
A nursing note for Resident 12 dated July 27, 2026, at 12:27 p.m. revealed the resident had a change in condition, was sent to the hospital for evaluation and was admitted.
Review of Resident 12's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding his hospitalization on July 27, 2026.
A quarterly MDS for Resident 76 dated June 30, 2026, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.
A nursing note for Resident 76 dated July 12, 2026, at 1:30 p.m. revealed the resident had difficulty swallowing, was sent to the hospital for evaluation and was admitted.
A nursing note for Resident 76 dated July 17, 2026, at 4:29 p.m. revealed the resident continued to have difficulty swallowing, was sent to the hospital for evaluation and was admitted.
Review of Resident 76's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalization on July 12, 17, 2026.
A quarterly MDS for Resident 100 dated April 29, 2026, revealed that the resident was cognitively impaired and was dependent on staff for daily care needs.
A nursing note for Resident 100 dated April 22, 2026, at 9:58 a.m. revealed the resident had difficulty breathing, was sent to the hospital for evaluation and was admitted.
A nursing note for Resident 100 dated October 26, 2026, at 11:39 p.m. revealed the resident had a choking episode, was sent to the hospital for evaluation and was admitted.
Review of Resident 100's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalizations on April 22 and October 26, 2026.
A quarterly MDS for Resident 144 dated April 1, 2026, revealed that the resident was cognitively intact, was dependent on staff for daily care needs.
A nursing note for Resident 144 dated May 23, 2026, at 5:03 a.m. revealed the resident had a large amount of blood in her brief and was being sent to the emergency room for evaluation.
Interview with the Director of Nursing on July 29, 2026, at 2:12 p.m. confirmed that for Residents 1, 4, 7, 12, 76, 100, 144, there was no written notification of hospital transfer provided to them or their representatives, and that the ombudsman was not notified of the transfer to the hospital as required.
28 Pa. Code 201.29(j) Resident Rights.
| | Plan of Correction - To be completed: 09/15/2026
F0628 – Discharge Process
1. Due to the time periods and circumstances of the residents identified during the annual survey, letters cannot be issued.
2. An audit will be completed by the administrator of the residents who are currently in the hospital due to a transfer prior to August 3, 2026, and the letters will be delivered/mailed to the residents/representatives and the ombudsman.
3. The administrator/designee will provide education on the Emergent Transfer/Discharge process to the social services and admissions staff.
Weekly audits will be conducted for 4 weeks by the Administrator/designee of the Emergent Transfers/ Discharges verifying that the letters were delivered/mailed to the residents/representative and the ombudsman.
4. The monthly listing of the Emergent Transfers/Discharges will be sent to the State LTC-Ombudsman by the Administrator.
A summary of the weekly audits will be compiled and reported by the Administrator in the monthly Quality Assurance and Process Improvement meeting for 3 months.
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