§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 a review of clinical records, facility policy, documentation provided to residents regarding transfers from the facility, records obtained from the acute care hospital, facility census records, and staff interviews, it was determined the facility failed to ensure an appropriate discharge by failing to permit a resident to return to the facility following hospitalization in accordance with its policies for one of five residents reviewed (Resident 1).
Findings include:
A review of the facility policy titled "Bed-Holds and Returns" (no revision date identified) revealed the facility policy required that all residents and their representatives receive written information regarding the facility's bed-hold policy, which addresses the holding or reservation of a resident's bed during hospitalization or therapeutic leave (a temporary absence from the facility for therapeutic purposes). The policy required that residents, regardless of payer source (the source responsible for payment of a resident's care, such as Medicare, Medicaid, private insurance, or private pay), receive written notice of the facility's bed-hold and return policies and that all residents be permitted to return to the facility following hospitalization or therapeutic leave in accordance with applicable federal requirements.
A review of Resident 1's clinical record revealed the resident was admitted to the facility on June 22, 2026. The clinical record revealed Resident 1 was transferred from the facility to an acute care hospital (a hospital that provides short-term medical or surgical treatment) on July 4, 2026, for evaluation and treatment of a displaced suprapubic catheter (SPC), a tube surgically inserted through the lower abdomen into the bladder to drain urine. A displaced suprapubic catheter occurs when the catheter becomes partially or completely dislodged from the bladder, which may result from a deflated or ruptured retention balloon, accidental traction on the catheter tubing, or inadequate securement of the catheter.
A review of the acute care hospital case management notes revealed documentation that the hospital case manager contacted the facility to arrange Resident 1's return following hospitalization. Documentation dated July 9, 2026, at 3:26 PM, revealed the facility informed the hospital case manager that no bed was available for Resident 1's return to the facility.
A review of the facility census dated July 9, 2026, revealed the facility had 30 available beds on the date it informed the hospital that no bed was available for Resident 1's return.
During an interview conducted on July 29, 2026, at 10:50 AM, the Nursing Home Administrator stated the facility believed Resident 1 was dissatisfied with the care previously provided and indicated the resident's family had contacted the Area Agency on Aging (AAA), an organization that advocates for and provides services to older adults and individuals with disabilities, regarding concerns about the care provided by the facility. The Nursing Home Administrator stated the facility determined there was no appropriate bed available for Resident 1 to return despite the resident having been admitted to and cared for by the facility before the hospitalization.
A review of the clinical record failed to identify documented evidence the facility conducted an interdisciplinary evaluation to determine whether it could continue to meet Resident 1's care needs following hospitalization. There was no documented evidence that the facility assessed the resident's post-hospital condition, identified specific clinical needs the facility could no longer meet, or documented the basis for concluding the resident could not safely return. In addition, there was no documented evidence that the facility coordinated discharge planning with the hospital or took steps to facilitate the resident's return.
During an interview on July 29, 2026, the Nursing Home Administrator and Director of Nursing both acknowledged Resident 1 had a complex medical history and stated the facility determined it could not meet the resident's needs because the resident was dissatisfied with the care previously provided. However, they were unable to provide documented evidence demonstrating the facility conducted a formal clinical assessment supporting that determination or explaining why the facility could no longer meet the resident's needs despite previously providing care to the resident and having 30 available beds at the time the hospital requested the resident's return.
28 Pa Code 201.18 (b)(1) Management.
28 Pa Code 201.29 (b)Resident rights.
| | Plan of Correction - To be completed: 08/25/2026
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance.
The facility cannot retroactively correct the residents return to the facility.
Current residents in the hospital on a bedhold will be reviewed to assess the residents post hospital condition for the resident to safely return.
The IDT team, including but not limited to the admissions director, will be educated regarding the Bedholds and Returns Policy.
Future residents in the hospital will be assessed for the post hospital condition to conclude that the resident can safely return.
Residents on a bedhold determined to be a safe return will be reviewed monthly at QAPI x 2 months.
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