Health inspection·February 27, 2026

483.15 Admission, transfer, and discharge rights. (c) Transfer and discharge - 42 CFR 483.15(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. Non-payment 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. 42 CFR 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 72523 (a) - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Tit. 22, 70717(f)(1) - Admission, Transfer and Discharge Policies (f) No patient shall be transferred or discharged solely for the purpose of effecting a transfer from a hospital to another health facility unless: (1) Arrangements have been made in advance for admission to such health facility. Tit. 22, 72527 (a)(6) - 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: (1) To be fully informed, as evidenced by the patient's written acknowledgement prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing patient conduct. (2) To be fully informed, prior to or at the time of admission and during stay, of services available in the facility and of related charges, including any charges for services not covered by the facility's basic per diem rate or not covered under Titles XVIII or XIX of the Social Security Act. (3) To be fully informed by a physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total plan of care including the identification of medical, nursing and psychosocial needs and the planning of related services. (4) To consent to or to refuse any treatment or procedure or participation in experimental research. (5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 72528(b). (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 11/13/25 the Department received a complaint regarding resident admission, transfer, and discharge rights. On 12/2/25, an unannounced visit was conducted at the facility to investigate a complaint allegation the facility refusing to readmit Resident 1 back to the facility. The facility failed to re-admit Resident 1, a 57-year-old-male, who had been residing at the facility since 12/09/2024, after Resident 1 was discharged from the general acute care hospital (GACH) and was medically cleared and requesting to come back to the facility. These deficient practices resulted in Resident 1 being admitted to an acute care hospital and not being readmitted to the facility per the court order issued. The Resident stayed in the acute care hospital awaiting placement for 34 days and was discharged to another skilled nursing facility 108 miles away on 11/17/25. Resident 1 experienced loss of safety, homelessness, delay in care by not returning to his home (the SNF) and had the potential for psychosocial harm. During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on 12/9/24 with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves). During a review of Resident 1's "Minimum Data Set (MDS a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment)" dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was "15" out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of Resident 1's, "Progress Note (PN)", dated 10/09/25, the PN indicated, "... After a careful review of the nursing progress notes regarding [Resident 1] behavior and an interview with [Resident 1], [Physician name] placed [Resident 1] on a 72-hour psychiatric hold. [Physician Name] then spoke to [Resident 1] again and informed him that he was now on a 72-hour psychiatric hold and was being transported to [Acute Care Hospital] for further evaluation...". The PN indicated Resident 1 was transferred to the acute care hospital on 10/9/25. During a review of Resident 1's care plan titled, "Non Compliance", undated, the care plan indicated, "... [Resident 1] pockets pills to save so he can take them all at once and feel them, resident insist consuming alcohol beverages despite physicians discontinuing it. Will [delivery service name] alcohol and will tell staff that he can do it..." During a review of Resident 1's hospital document titled, "Case Management Note", dated 10/16/25, the note indicated, "... [skilled nursing facility] today to address why the SNF continues to refuse to accept the pt back..." During a review of Resident 1's hospital document titled, "Patient Care Conference", dated 10/16/25, the document indicated, "... Patient is medically clear however [skilled nursing facility name] is declining to accept the pt back for LTC..." During a review of Resident 1's hospital document titled, "Supplemental Review", dated 10/19/25, the document indicated, "... Patient is unable to return back to [Skilled nursing facility name] for long term care due to behavior issues. Case management is unable to secure a new SNF as patient is at baseline..." During a review of Resident 1's hospital document titled, "Case Management Note", dated 10/21/25, the note indicated, "... [skilled nursing facility] today to address why the SNF continues to refuse to accept the pt back... [social worker] followed up with patient and per patient, he is requesting to return to the same [skilled nursing facility]. Patient noted he has nowhere to discharge to is homeless and has no social support... Patient was advised of barriers for discharge and per patient, he is not agreeable to discharge to another skilled nursing facility..." During a review of Resident 1's hospital document titled, "Case Management Note", dated 10/29/25, the note indicated, "... Skilled nursing facility referrals to be sent out and there are no acceptance. Patient has a length of stay of 20 days. Patient was a long-term resident of [skilled nursing facility name] but due to behaviors the skilled nursing facility has refused to accept pt back...". During a review of Resident 1's hospital document titled, "Case Management Note", dated 11/3/25, the note indicated, "... Patient will be discharging home with their [family member] ...". The note indicated Resident 1 would be discharging from the hospital to a family member's home. During a review of Resident 1's hospital document titled, "Case Management Note", dated 11/4/25, "... Transportation has been arranged for pick-up at 1200 for tomorrow, 11/5/25...". The note indicated that the hospital arranged for Resident 1's transfer and discharge. During a review of Resident 1's hospital document titled, "Supplemental Review", dated 11/7/25, "... Per patient, home with [family member] and is refusing to return home due to not having a care giver. Patient requested for long term care placement at a skilled nursing facility... patient is a readmit in less than 30 days and previously discharge home with [family member] ...". The document indicated Resident 1 was readmitted to the hospital following his discharge on 11/5/25, due to not having a care giver. During a review of document titled, "Department of Health Care Services Office of Administrative Hearings and Appeals", dated 11/7/25, the document indicated, "... The appeal is granted [Facility Name] has not met the legal requirements to involuntary discharge [Resident 1]. Therefore, facility must follow the required procedures to appropriately discharge Resident... Resident was transferred to hospital and facility refused to readmit Resident... Facility is not excused from complying with the discharge requirements... before discharging a resident, a long term care facility must provide proper notice, identify and establish a legally permissible reason for the discharge, adequately document the reasons for the discharge in the medical record, and provide sufficient preparation and orientation to ensure a safe and orderly discharge from the facility... in this case, facility transferred Resident to hospital and has not actually discharged Resident to a location that can meet his needs... Facility must readmit Resident and find a suitable discharge location or coordinate a discharge to another location that can meet his needs. Therefore, coordinating a safe discharge does not stop in this case even though Resident is not in Facility. If Facility has not readmitted Resident as of the date of this certification, Facility must file subsequent certifications of compliance every seven days until it certifies that Resident was readmitted to Facility or the Department excuses this requirement. Filing a certification does not excuse Facility's failure to comply with any terms of the Decision and Order..." During a review of Resident 1's hospital note titled, "Case Management Note", dated 11/10/25 the note indicated, "... Social worker consulted with [Registered Nurse] and escalated barriers for discharge to [skilled nursing facilities-SNF] to Leadership team... Statewide search for long term care placement at a SNF has been sent out and there are no acceptance. [Patient] came from home with daughter and per patient, is refusing to return due to not having support..." During a review of Resident 1's hospital note titled, "Emergency Department Note- Social worker Note", dated 11/17/25, the note indicated, "... Patient accepted at [Facility Name] for long term care. family unable to care for patient. [Social worker] spoke with [Family Member] patients need to be at a care facility, family unable to care for him. [Social worker] made patient aware that he has accepting [accepted] placement, at first patient was upset, because he does not want to be at a care center, stated he would rather be on the street. Patient is bed bound, unable to ambulate due to functional status. Patient made aware being on the streets in his condition would be unsafe. Patient recently was home with [family member] and [family member] was unable to care for him...". The Note indicated Resident 1 was discharged from the ACH to a skilled nursing facility on 11/17/25. During an interview on 12/2/25 at 10:49 a.m. with the administrator (ADM), the ADM stated Resident 1 was not readmitted into the facility since the court order to readmit Resident 1 was ordered on 11/7/25. The ADM stated the facility was informed by the acute care hospital (ACH)that Resident 1 would be admitted to another skilled nursing facility. During a phone interview on 12/3/25 at 3:11 p.m. with Resident 1, Resident 1 stated he was informed that the facility was refusing to readmit him. Resident 1 stated his preference was to return to the facility as soon as possible. Resident 1 stated he was informed by the facility that they would not be re-admitting him following the court order on 11/7/25. During a phone interview on 1/14/26 at 8:30 a.m. with the Admissions Nurse, in Resident 1's current skilled nursing facility. The admissions nurse indicated Resident 1 was admitted on 11/17/25 from the acute care hospital and had been residing in the facility since the day of transfer. During a review of the initial facility's policy and procedure (P&P) titled, "Transfer and Discharge", dated 12/19/22, the P&P indicated, "... It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances... Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected...The facility's transfer discharge notice will be provided to the resident and the resident's representative in a language and manner they can understand... the notice must be provided at least 30 days prior to a facility initiated t