§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
§483.15(c)(1)(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A)The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B)The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C)The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D)The health of individuals in the facility would otherwise be endangered;
(E)The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F)The facility ceases to operate.
§483.15(c)(1)(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.
§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.
(i)Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii)The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
§483.15(c)(7) Orientation for transfer or discharge.
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i)A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services
(ii)If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
§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:
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
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Observations:
Based on review of facility policy, facility documents, and clinical records, and staff interview, it was determined that the facility failed to have sufficient evidence why a resident wasn't readmitted to the facility following a hospitalization and failed to demonstrate that a resident's discharge from the facility was appropriate after transferring to the hospital for one of one residents reviewed (Resident R1).
Findings include:
Review of facility policy entitled "Transfer, Discharge, and Room Change" dated 12/5/25, indicated "The Manor determines that the transfer or discharge is necessary ... and the resident's needs cannot be met in the Manor. The resident's physician must document evidence in the resident's clinical record that the transfer/discharge is necessary."
Review of facility document "Bed Holds &; Leave of Absence" under Ineligibility to Return indicated "you may not be eligible for readmission even if you elect to hold a bed if your needs cannot be met by the facility you will be notified in writing if the situation arises."
Review of Resident R1's clinical record revealed an admission date of 6/7/26, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body) hypertension (high blood pressure) and hemiparesis (a condition where a person has weakness on one side of the body causing difficulty moving and impaired coordination).
Review of Resident R1's progress notes indicated the following:
Progress noted dated 7/6/26, indicated Resident R1 was transferred to the hospital due to behavior issues.
Progress note also indicated that Resident R1 had behaviors when staff were providing care due to pain.
Progress note dated 7/7/26, indicated that Resident R1 was admitted to the hospital related to hematoma that was found on CT [computed tomography - an x-ray machine that combines multiple X-ray images taken from different angles to produce detailed 3D images] scan.
Progress note dated 7/9/26, indicated that Resident R1 was discharged 7/6/26, with return anticipated.
Review of Resident R1's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 7/6/26, Section A Entry/discharge reporting under A0310 was answered Discharge return anticipated.
Review of Resident R1's bed holds and leave of absence document dated 6/8/26, indicated that Resident R1 wanted a bed held for the leave days paid for by Medicaid.
Review of Resident R1's bed holds and leave of absence document for his/her transfer on 7/6/26, indicated "Per NHA [Nursing Home Administrator] denial to readmit with central intake dated 7/8/26."
Review of Resident R1's transfer notice dated 7/6/26, indicated that he/she was being transferred due to behaviors and his/her welfare and needs could not be met in the facility.
Review of Resident R1's clinical record lacked the following evidence: that Resident R1 was notified in writing regarding his/her bed not being held, documented evidence by a physician of what needs he/she needed that the facility could not meet, and documented communication between the facility and hospital of his/her current clinical status.
Review of Resident R1's behavior documentation for July 2026, in tasks (area where the nursing assistants document) revealed Resident R1 had behaviors on the 7/1/26, 7/4/26, and 7/5/26. The documentation lacked evidence that the facility could not meet Resident R1's needs.
Review of Resident R1's Medication Administration Record (MAR) for July 2026, revealed an order dated 6/7/26, "Observe closely for significant side effects of Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift Document "Y" if monitored and none of the above observed. "N" if monitored and any of the above was observed, select chart code "Other/See nurses notes' and progress note findings." N was documented on the following:
7/1/26 on day shift
7/2/26, on afternoon shift7/4/26, on day shift
7/5/26, on day and afternoon shifts.
Review of Resident R1's progress notes revealed no documentation indicating what side effects were observed and lacked evidence that the facility could not meet Resident R1's needs.
During an interview on 8/31/26, at 11:00 a.m. the Director of Nursing confirmed that Resident R1 was discharged from the facility, and the facility was unable to meet Resident R1's needs due to his/her behaviors. He/she also confirmed that Resident R1's clinical record lacked evidence of a written reason from the physician why the facility could not meet Resident R1's needs.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.29 (a) Resident rights
28 Pa. Code 211.12 (d)(3) Nursing services
| | Plan of Correction - To be completed: 10/16/2026
The facility has not yet received a referral regarding a readmission request from the hospital, nor from resident R1, nor from the resident's emergency contact, therefore the facility is unable to readmit the resident to the facility.
Going forward, if the facility cannot meet the needs of a resident due to behaviors, the Director of Nursing and/or designee will ensure that the clinical record contains evidence of a written reason from the physician why the facility could not meet the needs of a resident. For Quality Assurance purposes, the facility will conduct a 30-day look back to ensure that all residents who were sent out to the hospital, that have not yet been readmitted, have proper documentation to support a discharge/transfer.
The Director of Nursing and/or designee will educate the Medical Director, Assistant Director of Nursing, and Charge Nurses on the importance of following the policy titled "Notification of Change" to ensure that all notifications of significant changes resulting in transfer to the hospital occur per policy. Also, they will be educated on the "transfer, discharge, room change policy."
The Director of Nursing and/or designee will conduct audits of all transferred residents 3 times a week for 4 weeks. If the transfer was due to the facility not being able to meet the needs of a resident, the Director of Nursing will ensure that there is supporting documentation from the physician in the clinical record. The results of the audits will be reviewed at upcoming Quality Assurance and Performance Improvement meeting.
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