Health inspection·December 3, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the facility did not transfer or discharge a resident in an unsafe manner for one of three sampled residents (Resident 1) when Resident 1 was transferred to recuperative care (a short-term, supportive housing program for people experiencing homelessness who are recovering from an illness or injury but are not sick enough to need a hospital anymore) prior to confirming recuperative care would accept Resident 1. This deficient practice resulted in Resident 1's admission to the hospital after recuperative care did not accept Resident 1's transfer.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 7/15/2025, and readmitted on [DATE], with diagnoses including Guillain-Barre Syndrome (a condition where the body's immune system mistakenly attacks its own nerves, causing weakness, tingling, and sometimes paralysis) and hypertension (high blood pressure).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/17/2025, the MDS indicated Resident 1 had no impairment with thought processes and required partial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Psychosocial Assessment/Social History/Discharge Planning, dated 7/17/2025, Psychosocial Assessment/Social History/Discharge Planning indicated Resident 1 will be discharged back to recuperative care when discharged from the facility. During a review of Resident 1's Progress Notes, dated 10/3/2025, the progress notes indicated the Outside Social Service Worker (OSSW) found placement at a recuperative care for Resident 1 and would like to discharge Resident 1 on 10/8/2025 at 11 a.m. The progress note indicated Resident 1 was made aware and Resident 1 agreed. During a review of Resident 1's Progress Notes, dated 10/8/2025, at 10:00 a.m., the progress notes indicated Resident 1 was discharged from the facility at 9:50 a.m. via transportation with all his medications and belongings. During a review of Resident 1's Progress Notes, dated 10/8/2025, at 11:23 a.m., the progress notes indicated the OSSW informed the facility that Resident 1 was not accepted in recuperative care due to Resident 1's medical condition. The progress notes indicated the facility informed the OSSW that Resident 1 had already left the facility and was on the way to recuperative care. The progress notes indicated the OSSW stated that she called Resident 1 already and offered to help the resident to be placed at a motel or a shelter, but Resident 1 refused.During an interview on 10/15/2025 at 9:48 a.m. with Resident 1, Resident 1 stated that after leaving the facility, the OSSW called and informed Resident 1 that recuperative care will not accept Resident 1 due to his medical condition. Resident 1 stated that after receiving the call from OSSW he came back to the facility parking lot and asked the facility to help him to talk to the OSSW. Resident 1 stated that transportation came in again and he left the facility accompanied by the Assistant Social Worker (ASSW) and dropped him off at the hospital. Resident 1 stated the ASSW did not check him and left Resident 1 in the parking lot in front of the Page 1 of 2 055307 055307 12/03/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital. Resident 1 stated he walked himself to emergency room from the parking lot.During an interview on 10/15/2025 at 10:33 a.m. with the ASSW, the ASSW stated the facility received a call from the OSSW informing the facility that recuperative care was not taking Resident 1 due to his medical condition. The ASSW stated that Resident 1 was aware and was already on the way back to the facility. The ASSW stated that the OSSW suggested to transfer to a few places, but Resident 1 refused and the OSSW suggested the hospital and Resident 1 agreed. The ASSW stated that she accompanied Resident 1 to the hospital, helped Resident 1 to unload all his belongings from the transportation, and left Resident 1 in front of the hospital parking lot. The ASSW stated that she left when Resident 1 was already walking inside and talking to someone from the hospital. During an interview on 10/15/2025 at 11:08 a.m. with Social Service Worker (SSW) 1, SSW 1 stated that Resident 1 was already discharged from the facility and SSW 1 received a call from the OSSW that Resident 1 will not be accepted into recuperative care due to Resident 1's medical condition. SSW 1 stated Resident 1 returned to the facility and Resident 1 was upset and wanted to talk to the OSSW. SSW 1 stated that the facility called the OSSW for Resident 1 and the OSSW offered a board and care or a motel, but Resident 1 refused. SSW 1 stated Resident 1 wanted to go to the streets, but the OSSW offered the hospital and Resident 1 agreed. SSW 1 stated that the ASSW accompanied Resident 1 to the hospital. During an interview on 10/15/2025 at 11:36 a.m. with the Administrator, the Administrator stated Resident 1 wanted to be in the streets and refused to go back in the facility. The Administrator stated that the OSSW offered the hospital and Resident 1 agreed to be sent to the hospital. During an interview on 10/15/2025 at 11:57 a.m. with Resident 1, Resident 1 stated that he agreed to be discharged to the hospital because the facility told me the hospital will help me to find placement. During an interview on 10/15/2025 at 12:25 p.m. with the OSSW, the OSSW stated when Resident 1 left the facility, the recuperative care informed her that recuperative care denied Resident 1 due to his medical condition. During an interview on 10/16/2025 at 10:37 a.m. with SSW 1, SSW 1 stated the facility does not have any written contract or agreement from the OSSW. SSW 1 stated the facility does not have any proof or any written documentation that Resident 1 was officially accepted to recuperative care. SSW 1 stated the facility only has verbal and email communication from the OSSW that Resident 1 was accepted into recuperative care. SSW 1 stated the facility did not receive confirmation of Resident 1's acceptance into recuperative care. SSW 1 stated the facility should have confirmation that the recuperative care accepted Resident 1 before discharging the resident from the facility. During an interview on 10/16/2025 at 11:14 a.m. with the Administrator, the Administrator stated that the facility failed to get confirmation from the recuperative care that they will accept Resident 1. The Administrator stated the facility was informed that the recuperative care will not take Resident 1 after Resident 1 left the facility. During an interview on 10/16/2025 at 12:32 p.m. with the Director of Nursing (DON), the DON stated the facility should have a written contract indicating the confirmation that the receiving facility will take the resident before the facility discharges the resident because there is a potential that the receiving facility could deny the resident's transfer in the last minute after discharging the resident from the facility.During a review of the facility policy and procedure (P&P) titled, Transfer and Discharge, last reviewed 10/2024, the P&P indicated, the staff provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. 055307 Page 2 of 2