Health inspection·December 31, 2025

Title 42, Section 483.10 Resident rights (a) The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. Title 42, Section 483.15(c) Transfer and discharge (c)(1) Facility requirements- (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. (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. Title 42, Section 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. Title 42, Section 483.15(c)(3) Notice before transfer (3) 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. Title 42, Section 483.15(c)(4) Timing of the notice (i) Except as specified in paragraphs (c)(4)(ii) and (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. Title 42, Section 483.15(c)(5) Contents of the notice (5) 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; Title 42, Section 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. Title 22, Section 72521. Administrative Policies and Procedures (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. Title 22, Section 72527. Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. On 10/8/25 at 1:45 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of admission, transfer and discharge rights that occurred on 9/24/25. Based on interview and record review, the facility failed to ensure a safe and appropriate discharge was provided to one of three sampled residents (Resident 1), when Resident 1 was not permitted admission to the facility upon return from a day leave and was discharged to her car. This failure resulted in Resident 1's unanticipated discharge and homelessness with no resources, medical care, or information on how to file an appeal. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 6/1/25 with diagnoses which included a right femur (thigh bone) fracture, history of venous thrombosis (blood clot in the veins of the legs), embolism (when the blood clot breaks off and travels to another part of the body, commonly the lungs), localized edema (swelling from trauma, surgery or thrombosis), and chronic kidney disease (damage and dysfunction to the kidneys). A review of Resident 1's "Nurse Practitioner Progress Notes" (NPPN) dated 7/31/25 at 10:36 p.m., indicated Resident 1 was a "high risk for re-hospitalization." A review of Resident 1's Minimum Data Set (MDS, federally mandated Resident assessment tool), dated 9/5/25, indicated Resident 1 was cognitively intact and capable of making her own decisions. A review of the "Discharge Summary," dated 9/11/25 at 10:27 a.m., indicated the physician documented, "Discharge disposition to: Transfer pt [Resident] to custodial [personal care or long-term support and is focused on meeting a person's basic needs to ensure their comfort and dignity] until placement is secured. Pt needs placement because she is homeless. [Resident 1] will be transferred back to custodial care until a placement is secured." A review of Resident 1's Care Plan Conference Notes, dated 9/18/25 at 10:42 a.m., indicated Resident 1's discharge plan was to transfer from skilled to custodial care until placement was secured. A review of the "Social Services Notes," dated 9/24/25 at 2:33 p.m., indicated the Social Services Assistant (SSA) documented, "[Due to] Resident being out more than 4 [hours], it will be an AMA discharge." A review of the "Social Services Note," dated 9/24/25 at 2:45 p.m., indicated the Social Services Director (SSD) documented, "The Nurse Practitioner (NP) has been notified and is in agreement with proceeding with discharge. The Resident 's belongings and medications will be prepared and made available for pick-up." A review of Resident 1's NPN, dated 9/24/25 at 5:18 p.m., indicated the Director of Nursing (DON) documented, "The Resident came back to the facility at [4 p.m.] and it was discussed with the Resident that the MD [Medical Director] has DC'd [discharged] the Resident AMA." A review of a physician's order dated 9/24/25 at 6:23 p.m. indicated, "Resident discharge against medical advice..." A review of Resident 1's NPPN, dated 9/26/25 at 2:24 p.m. indicated, "Per the nursing notes, Resident 1 left AMA from the facility." The NP indicated she was not in the facility at the time of discharge. During a review of Resident 1's NPN, dated 9/24/25 through 9/26/25, there was no documentation which indicated Resident 1 had the desire to leave the facility AMA. The NPN did not include documentation that the risks and benefits of leaving the facility were discussed with the Resident , options or locations that would meet Resident 1's needs having been presented to the Resident , or if Resident 1 understood the reason for being discharged and her response to the discharge. During a telephone interview on 10/7/25 at 4:38 p.m., Resident 1 stated the discharge occurred on 9/24/25, while she was out on private business for a LOA (leave of absence) from the facility. Resident 1 indicated that when she returned to the facility that same day, staff notified her she could not return as a Resident , failed to assess her after her LOA, packed up her belongings, discharged her to her car, and the facility stated the Resident 's discharge was considered as "Against Medical Advice." Resident 1 indicated the facility wanted her to sign the AMA form, which she refused to sign, because it was not her decision. Resident 1 stated, "I'm homeless, I wasn't trying to leave against medical advice, that wasn't my decision, I didn't want to leave." Resident 1 further stated, "I was pretty traumatized that day, what do I do now? They made my life hell; their intention was to get rid of me and they did." Resident 1 indicated her discharge plan was to find placement in transitional housing and confirmed she is still "unhoused." During a concurrent interview and record review on 10/8/25 at 3:51 p.m. with the Assistant Director of Nursing (ADON), Resident 1's medical record and the facility's Policy and Procedure (P&P) for LOA was reviewed. The ADON confirmed there was no documented evidence in Resident 1's medical record that indicated staff attempted to contact the MD for an LOA order. The ADON stated staff should have contacted Resident 1's MD to request an LOA order, and documented the date and time of the request, the MD's decision and that education was provided to the Resident in the Resident 's medical record. The ADON stated, "[Resident 1] was going on LOAs, the last day [9/24/25] she overstayed her LOA." The ADON confirmed the LOA P&P did not indicate a time limit for an LOA or that a Resident will be discharged if the LOA P&P was not followed. During a concurrent interview and record review on 10/8/25 at 4:01 p.m. with the Social Services Director (SSD), Resident 1's medical record was reviewed from June 2025 through September 2025. The SSD acknowledged Resident 1 did not have a physician's order for an LOA. The SSD confirmed there was no documentation prior to 9/24/25 in Resident 1's medical record that discussed the facility's LOA process or procedure, the allotted hours Resident 1's insurance authorized for an LOA or that Resident 1 had been non-compliant with her plan of care. The SSD stated Resident 1 had been homeless when she was admitted to the facility and was on a transitional housing waitlist. The SSD stated, "Every day [Resident 1] would take off from the facility and would stay over five or six hours. I provided [Resident 1] with housing resources, but at that point it's on the Resident to follow through with the discharge placement." The SSD stated, "On that day [9/24/25] [Resident 1] left the facility around 10:30 a.m. and the decision to discharge her was because the Resident chose to drive her own car instead of having a ride." The SSD indicated for a Resident 's transfer or discharge the facility needed to provide the Resident with a "Notice of Transfer or Discharge" form which included information on how to file an appeal if the Resident did not agree with the transfer or discharge. The SSD confirmed there was no documentation provided to Resident 1 upon her discharge due to the physician's order to discharge her as AMA. The SSD stated, "We have to follow the doctor's orders. [Resident 1] did have a discharge plan, but she could not return to living in her car, [Resident 1] is homeless." The SSD admitted, "I wouldn't discharge a Resident to their car. That's not a safe discharge." The SSD acknowledged Resident 1 did not initiate the AMA discharge. During an interview on 10/23/25 at 11:37 a.m., the DON acknowledged AMA discharges were Resident initiated, not facility initiated, and confirmed the facility "was not allowed" to discharge a Resident while on a LOA. The DON acknowledged that when a Resident expressed a desire to leave AMA, the facility should educate the Resident, explain the risks and benefits of an AMA discharge, and provide follow-up information on where to get additional care and document the discussion in the Resident's medical record. The DON stated, "Since [Resident 1] was gone for more than four hours, the MD decided to DC the Resident AMA." During an interview on 10/23/25 at 12:32 p.m., the Administrator (Admin) acknowledged if a Resident verbalized a desire to leave the facility AMA then staff should attempt to provide the Resident with education, the risks and benefits between leaving the facility versus staying at the facility, supplies, and additional resources. The Admin indicated if a Resident returned to the facility after an identified LOA timeframe, the facility should have ensured the Resident was safe and provided the Resident with education on following MD orders and the facility's LOA P&P. During a telephone interview on 10/23/25 at 1:18 p.m., MD 1 confirmed an AMA discharge, by definition, was initiated by the Resident. MD 1 stated if a Resident indicated they wanted to leave the facility AMA and he [MD 1] was not at the facility at the time, he expected the facility staff to document the conversations between the Resident and staff which discussed the Resident's options, encouragement for the Resident to remain in the facility, what the negative o