Health inspection·August 29, 2025

F 0627 Level of Harm - Immediate jeopardy to resident health or safety 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 a safe and orderly discharge was provided to two of three sampled residents (Resident 1, who had severely impaired cognition [the mental action or process of acquiring knowledge and understanding through thought, experience and the senses], lacked capacity to understand and make decisions, and required staff assistance for all Activities of Daily Living [ADL - basic tasks that individuals perform to maintain their daily lives] and Resident 2, who also required staff assistance for all ADLs) by failing to:1. Ensure that the post-discharge destination and continuing care provider were capable of meeting the needs of Resident 1 and Resident 2 prior to discharge. 2. Ensure that an effective discharge plan addressing the health and safety needs of Resident 1 and Resident 2 was provided by failing to complete all sections of the Post-Discharge Plan of Care for both residents (Resident 1 and Resident 2). 3. Ensure that the physicians for Resident 1 and Resident 2 documented information about the basis for the discharge in their medical records. 4. Implement the following facility discharge policies and procedures (P&P): - Transfer or Discharge, preparing a Resident for - indicating residents will be prepared in advance for discharge.- Discharge Summary and Plan - indicating a discharge summary and post-discharge plan will be developed and re-evaluated by the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their resident) to assist the resident to adjust to his/her new living environment.These deficient practices resulted in Resident and Resident 2 being discharged to an unlicensed Board and Care (BC 1 - small residential homes that provide room, meals, and assistance with daily living activities for individuals needing care, but don't require 24-hour skilled nursing care) on 8/8/2025. On 8/19/2025, Resident 1 required an emergency transfer from BC 1 to General Acute Care Hospital 1 (GACH 1) and was treated for anorexia (a general loss of appetite that can be caused by illness or medications), altered level of consciousness (ALOC - when a person is not as awake, alert, or responsive to their surroundings as they should be), pulmonary congestion (abnormal buildup of fluid in the lungs) and urinary tract infection (UTI - an infection in the bladder [muscular organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine]) and possible early sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). Resident 1 was then transferred to Skilled Nursing Facility 2 (SNF 2) on 8/26/2025.On 8/19/2025, Resident 2 required transfer from BC 1 to GACH 2 and was treated for hyperkalemia (abnormally high potassium [an essential mineral crucial for the proper functioning of the body including nerve function, muscle contractions and maintain a regular heartbeat, normal range: 3.5 to 5.2 milliequivalent per liter {mEq/l - unit of measure}] levels in the blood and can be life-threatening, especially if it develops quickly, as it can cause serious heart problems like irregular rhythms, muscle weakness, or even paralysis [inability to move]). Resident 2 was then transferred back to Skilled Nursing Page 1 of 8 056133 056133 08/29/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Facility 1 (SNF 1) on 8/21/2025.On 8/28/2025 at 3:28 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Quality Assurance Nurse Consultant (QANC) and the Medical Records Director (MRD) due to the facility's failure to ensure Resident 1 and Resident 2 were provided with a safe and orderly discharge when on 8/8/2025, Resident 1 and Resident 2 were discharged to an unlicensed board and care (BC 1).On 8/29/2025 at 2:15 p.m., the QANC provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility's failure to ensure Resident 1 and Resident 2 were provided with a safe and orderly discharge when on 8/8/2025, Resident 1 and Resident 2 were discharged to an unlicensed board and care (BC 1).On 8/29/2025 at 4:44 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the accepted IJ removal plan through observations, interviews and record reviews, and determined the IJ situation regarding facility's failure to ensure Resident 1 and Resident 2 were provided with a safe and orderly discharge was no longer present. The SSA removed the IJ on 8/29/2025 at 5:19 p.m., in the presence of the ADM and QANC.The acceptable IJ Removal Plan included the following summarized actions:1. Resident 1 is no longer at the facility. Resident 1 was discharged to a lower level of care (BC 1) on 8/8/2025. During a welfare check (a service to ensure the well-being of a resident) conducted on 8/27/2025, the facility found out that Resident 1 had been admitted to GACH 1. Facility staff contacted GACH 1 and found out that Resident 1 had been discharged to SNF 2 on 8/26/2025. The facility then completed a welfare check with SNF 2 and was able to speak directly with Resident 1. Resident 1 stated that he (Resident 1) is doing well and is receiving appropriate care and services at SNF 2. 2. Resident 2 was discharged from the facility on 8/8/2025 to a lower level of care (BC 1) and was readmitted to the facility (SNF 1) on 8/21/2025 and remains in-house. On 8/22/2025, the Social Services Assistant (SSAT) conducted a Psychosocial (refers to the mental, emotional, social and spiritual needs of residents, encompassing their feelings, relationships, coping mechanisms and over-all sense of well-being) Assessment and Trauma (deeply distressing or disturbing experience that overwhelms a resident's ability to cope) Evaluation, which identified no signs of emotional distress (refers to a state of mental suffering caused by difficult or overwhelming situations, can affect a resident's mood, thoughts, and behavior, and may interfere with daily functioning) or trauma. 3. On 8/28/2025, the ADM initiated an in-service (refers to educational or training sessions) training for the attending physicians, including the Medical Director, on the regulation concerning required documentation upon discharge of the resident to lower level of care, focusing on the information about the basis for transfer or discharge. Physicians, nurse practitioners (registered nurses with advanced education and clinical training who provide direct patient care services including diagnosing and treating illness, prescribing medications), and physician assistants (licensed and highly skilled healthcare professional, often under the supervision of a physician who provide patient care services including diagnosing illness, treating diseases, ordering tests and prescribing medications) who were unable to attend the in-person in-service were contacted by the ADM and provided the in-service training by phone. 4. Effective 8/28/2025, the facility will ensure that the resident, family, or responsible party (RP) is actively included in the discharge planning process. The facility will provide the resident and/or representative with the opportunity to participate in the selection of the post-discharge placement and ensure they are given the option to visit and inspect the receiving facility prior to discharge. 5. Effective 8/28/2025, the facility will conduct a welfare check on residents discharged to a lower level of care to evaluate the 056133 Page 2 of 8 056133 08/29/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few appropriateness of the placement, confirm adequate staffing is in place and identify any additional services the resident may need. 6. Effective 8/28/2025, the Social Services designee will document in the progress notes the discharge planning process, including details about the lower level of care facility (board and care), its licensing status, and the name and contact information of the transportation company assigned to pick up the resident from the facility. 7. On 8/28/2025, the ADM notified all licensed nurses, social service personnel, and the Medical Director of the findings outlined in the IJ template dated 8/28/2025 and conducted in-services training on the facility's Transfer and Discharge policy. 8. Social Services designee reviewed all resident discharges from the past three (3) months (June 2025, July 2025, August 2025) to verify the placements to lower level of care, assess resident status and confirm that the receiving facilities were licensed. A total of 13 residents were identified as having been discharged to assisted living facility or other lower level of care facilities. All receiving facilities were verified to be licensed, and all residents were confirmed to be safe. No other residents were found to have been affected by the deficient practice. 9. The Medical Records designee reviewed and audited the discharge paperwork of the residents discharged from the facility over the past three (3) months (June 2025, July 2025, August 2025) to ensure completion of Post-Discharge Plan of Care and documentation by the physician regarding the basis for discharge. The audit identified three (3) residents with incomplete Post-Discharge Plan of Care and 11 residents with missing physician documentation outlining the basis for discharge. The Assistant Director of Nursing (ADON) will complete the missing information of the Post-Discharge Plan of Care and send copies to the respective residents, families, or responsible parties. The MRD/designee has notified the physicians of the regulatory requirement to document the basis for discharge in the resident's medical record. 10. Effective 8/28/2025, the ADM or Director of Nursing (DON) will conduct a monthly in-service training for all licensed nurses and social services staff on the facility's Transfer and Discharge policy. This training will occur monthly for a period of three (3) months. 11. On 8/28/2025, the ADM provided one-to-one (refers to a training session between one trainer, such as a supervisor, educator or mentor and one trainee, such as staff member) in-service training to the Social Services staff regarding the facility's Transfer and Discharge policy. The training emphasized the importance of verifying the receiving facility or provider to ensure a safe and appropriate discharge. Additionally, the ADM reinforced the need to document the discharge planning in the progress notes, including the name and contact information of the transportation company responsible for picking up the resident. 12. On 8/28/2025, the ADON and the QANC conducted an in-service training for all licensed nurses on the accurate and timely completion of the Post-Discharge Plan of Care, the discharge planning process, and the importance of documenting the physician's basis for discharge. Licensed staff who were unable to attend the in-service on 8/28/2025 will be contacted by phone and provided with the initial in-service training. Licensed staff who are on vacation, personal leave, or medical leave will receive the in-service training on their first scheduled day back to work. 13. Effective 8/28/2025, the DON or designee will participate in discharge IDT meetings to ensure that residents receive the necessary services based on their level of care needs and current clinical condition. This determination will be made through a thorough review of the rehabilitation discharge summary, Minimum Data Set (MDSa resident assessment tool), and physician notes as part of the discharge planning process. Residents and their family members or responsible party will be invited to attend and actively participate in the discharge planning. They will also be given the opportunity to choose a placement (lower level of care) and visit the selected facility prior to discharge. The facility will also assign designated staff to conduct an on-site visit to the chosen receiving facility to ensure 056133 Page 3 of 8 056133 08/29/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few it is licensed, adequately staffed and safe for the resident. The Social Services designee will invite Residential Care Facility for the Elderly (RCFE - a type of non-medical facility in California for people 60 years or older who need assistance with daily activities like dressing and bathing, as well as housing, meals, and general supervision, but do not require 24-hour nursing care) operators to visit the facility and assess the resident prior to discharge, to determine whether their facility can meet the resident's care needs. The Social Services designee will also be responsible for documenting the discharge planning process in the residents' progress notes. 14. On 8/28/2025, the MRD or designee and Social Services designee will initiate a Lower Level of Care Monitoring Log. This log will be used to track and verify all discharge and transfer details, including confirmation of receiving facility or provider information and documentation of discharge instructions. 15. Effective 8/28/2025, the MRD or designee will conduct a daily review of all discharges to ensure that the Post Discharge Plan of Care is completed accurately and in a timely manner, and that the physician documented the basis for discharge. Any identified deficiencies will be reported to the DON or designee for follow-up and completion of the required documentation. 16. Effective 8/28/2025, the DON and/or designee will review all discharges and transfers, documenting findings and any corrective action taken in the monitoring log for a period of three (3) months. If any issues are identified during this period, the DON will extend the monitoring for an additional three (3) months or until 100 percent (%) compliance is achieved.17. On 8/28/2025, the facility will initiate a Quality Assurance and Performance Improvement (QAPI- data driven and proactive approach to quality improvement) focused on the discharge and transfer process to address the findings outlined in the IJ template. The facility will review the progress every month for a period of three (3) months and will adjust the measures needed to ensure the development and implementation of an effective and consistent discharge and transfer process/plan. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/1/2025 with diagnoses that included metabolic encephalopathy (brain damage or loss of brain function that is caused by an illness or condition), fractures (break in a bone) of the fifth and sixth cervical vertebra (the seven bones that make up the neck region of the spine [backbone]) and unspecified psychosis (mental disorder characterized by a disconnection from reality). During a review of Resident 1's History & Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 4/3/2025, the H&P indicated that Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Psychiatric Evaluation (a comprehensive assessment of a resident's mental health status), dated 5/5/2025, the Psychiatric Evaluation indicated that Resident 1 was confused (difficulty thinking clearly, understanding, concentrating or making decisions), disoriented (a more specific type of confusion where the resident cannot correctly identify time, place, person or situation), forgetful and had no family. Resident 1's Psychiatric Evaluation further indicated that Resident 1 had episodes of mood swings, agitation (state of restlessness, irritability or emotional disturbance), screaming for no reason and was difficult to redirect. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear and needed assistance from staff with eating, oral hygiene, upper body dressing and personal hygiene. The MDS also indicated Resident 1 had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine and remains in place for an extended period of time) and always exhibited bowel incontinence (inability to control bowel movements). During a review of Resident 1's Physician's Order, dated 8/7/2025, timed at 11:57 a.m., the Physician's Order indicated to discharge Resident 1 to BC 1 on 8/8/2025. During 056133 Page 4 of 8 056133 08/29/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few a review of Resident 1's Notice of Proposed Transfer and Discharge, dated 8/8/2025, the Notice of Proposed Transfer and Discharge indicated that Resident 1 was discharged to BC 1 on 8/8/2025. The Notice of Proposed Transfer and Discharge also indicated that the reason for discharge was that Resident 1's health had improved sufficiently and no longer required the services provided by the facility. During a review of Resident 1's Discharge Summary Report, dated 8/8/2025, the Discharge Summary Report indicated Resident 1 was discharged to BC 1 on 8/8/2025 at 2:20 p.m. During a review of Resident 1's H&P from GACH 1, dated 8/20/2025, the H&P from GACH 1 indicated that Resident 1 was brought to GACH 1 (from BC 1) due to not eating for two (2) days at his (Resident 1) board and care. The H&P from GACH 1 also indicated that a social worker (not indicated) was concerned for elderly negligence (known as elder neglect, a form of elder abuse where a caregiver fails to provide the necessary care, assistance or supervision that an older adult needs to maintain their health and safety). During a review of Resident 1's Neurology (branch of medicine that deals with the study, diagnosis, and treatment of disorders related to the nervous system. This includes the brain, spinal cord, nerves and muscles.) Consultation from GACH 1, dated 8/20/2025, the Neurology Consultation indicated Resident 1 was at a different facility before (SNF 1) and was transferred to the new facility (BC 1), with seemingly very little care and knowledge of Resident 1 (including Resident 1's condition). The Neurology Consultation further indicated that the Emergency Medical Services (EMS - ambulance services, pre-hospital care or paramedic services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) call was placed not by the facility (BC 1) that Resident 1 was residing in, but from a social worker who was following up on Resident 1's well-being. During a review of Resident 1's Palliative (refers to care or treatment that focuses on relieving symptoms and improving quality of life) Care Notes from GACH 1, dated 8/21/2025, timed at 1:24 p.m., the Palliative Care Notes indicated Resident 1 was admitted with anorexia and ALOC. The Palliative Care Notes indicated Resident 1 was found to have pulmonary congestion, UTI and possible early sepsis. During Resident 1's stay at GACH 1, Resident 1 received intravenous (IV administered into a vein) fluids for hydration, IV antibiotics (medications used to treat bacterial infections, such as Ceftriaxone - an antibiotic used to treat bacterial infections) and respiratory treatments to address the pulmonary congestion. During a concurrent interview and record review on 8/26/2025 at 1:32 p.m., with the SSAT, Resident 1's Social Services Notes from 4/1/2025 to 8/8/2025 were reviewed. The SSAT stated that there were no discharge planning notes found, and no documented evidence found in Resident 1's medical record indicating who arranged Resident 1's transfer to BC 1. The SSAT stated that there should have been documentation in Resident 1's medical records reflecting coordination between the facility and BC 1. The SSAT further stated that when a resident is preparing for discharge, IDT meetings should be held with the resident and/or resident's RP to discuss discharge goals including involving them in selecting the location the resident will be discharged to, as well as ordering any durable medical equipment (DME medical devices and supplies prescribed by a healthcare provider for long-term or repeated use in the home to assist with daily activities and manage health conditions) or arranging home health (HH - skilled care or services that are provided to a resident while at home by a licensed health care professional). The SSAT stated that these steps were not completed for Resident 1. The SSAT further stated that she (SSAT) was not aware of Resident 1's discharge to BC 1 until after Resident 1 was discharged , when she (SSAT) was asked to make a follow-up call on 8/12/2025. The SSAT stated she (SSAT) made a follow-up call to Resident 1 on 8/12/25 and spoke to a caregiver at BC 1 (unable to recall name) who stated that Resident 1 was okay and there were no concerns. The SSAT stated she (SSAT) could not locate the phone number she (SSAT) used for the 056133 Page 5 of 8 056133 08/29/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few follow-up call, as it was not documented in Resident 1's medical records. The SSAT stated that as part of her (SSAT) role within the social services department, she (SSAT) is responsible for discharge planning, completing referrals to potential receiving facilities, arranging transportation, ordering HH or DME, and documenting all discharge-related coordination in the medical record. The SSAT stated that in the case of Resident 1, she (SSAT) was not informed of the discharge plan and was not involved in Resident 1's discharge process at any point. The SSAT further stated that she (SSAT) does not know who coordinated Resident 1's discharge with BC 1 and who arranged Resident 1's transportation to BC 1. During a concurrent interview and record review on 8/26/2025 at 3:10 p.m., with the ADON, Resident 1's Post Discharge Plan of Care dated 8/8/2025 was reviewed. The Post Discharge Plan of Care did not indicate the following: What type of destination Resident 1 was being discharged to, The phone number of the location Resident 1 was being discharged to. The information regarding Resident 1's responsible party, Resident 1's insurance information, The name and phone number for Resident 1's continuing care physician, Resident 1's diagnosis, Resident 1's allergies, Resident 1's skin condition, Resident 1s vital signs (key measurements that indicate how well a person's body is functioning), Resident 1's diagnostic tests (includes both laboratory tests [done using blood, urine, stool or other body fluids to check for abnormalities] and imaging tests [create pictures of structures inside the body], used to diagnose medical conditions) Resident 1's intake patterns and eating habits, Resident 1's medical equipment or supplies, Resident 1's assistive devices (refer to tools, equipment used to help residents maintain or improve their mobility, independence, safety and quality of life in daily activities), Resident 1's care preferences, Resident 1's specific care needs, safety precautions, treatment instructions, Date and time of Resident 1's last meal, Resident 1's last bowel elimination, If Resident 1's inventory checklist was completed, If Resident 1 had advance directive (a legal document that allows a person to communicate their wishes about medical care in advance, in case they become unable to speak or make decisions for themselves in the future due to illness, injury or incapacity) papers, Resident 1's community health services, If Resident 1 could administer his own medications, Any additional discharge planning notes for Resident 1, The address of the state ombudsman (advocate for residents in facility). The ADON confirmed that Resident 1's Post Discharge Plan of Care was missing the information listed above. The ADON stated that Resident 1's Post Discharge Plan of Care should have been completed to ensure that the accepting facility has all the necessary information to appropriately care for Resident 1. The ADON further stated that Resident 1's Post Discharge Plan of Care must be accurate and thorough to help ensure that Resident 1's needs are met after discharge. Regarding the timing of reviewing the Post Discharge Plan of Care with residents, the ADON stated that it is usually reviewed with residents on the day of discharge. The ADON stated he (ADON) was unaware that the facility's P&P indicated that the Post-Discharge Plan of Care was to be reviewed with the resident and/or the resident's RP at least 24 hours prior to discharge. The ADON stated he (ADON) understands the importance of reviewing the Post Discharge Plan of Care at least 24 hours prior to discharge to allow the resident time to understand the discharge plan, ask questions, and address any concerns before the actual discharge occurs. During an interview on 8/27/2025 at 10:45 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that he (RN 1) was the RN responsible for entering Resident 1's discharge order. RN 1 stated that on 8/7/2025 (unable to recall specific time), while sitting next to Resident 1's Medical Doctor (MD 1) at the nursing station, he (RN 1) overheard the Facility Marketer (FM) inform MD 1 that she (FM) had found placement for both Resident 1 and Resident 2. RN 1 stated he (RN 1) witnessed the FM write down the name and address of BC 1 on a piece of paper and hand it to MD 1. RN 1 further stated that he (RN 1) overheard MD 1 ask the FM 056133 Page 6 of 8 056133 08/29/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few whether the discharge would be safe, to which the FM stated Yes. RN 1 stated that MD 1 then wrote a discharge order for Resident 1, and RN 1 subsequently entered the order into the system. RN 1 stated that he (RN 1) texted Resident 2's Medical Doctor (MD 2) to ask whether he (MD 2) also wanted to discharge Resident 2 to BC 1. RN 1 stated that MD 2 responded with an order to proceed with the discharge of Resident 2 to BC 1, which he (RN 1) then entered into the system as well. RN 1 stated his (RN 1) role in the discharge process is to carry out the physician's orders and complete all required discharge paperwork. RN 1 stated that the licensed nurse is also responsible for reviewing the discharge paperwork with the resident and/or their RP, reviewing the prescribed medications, checking the resident's inventory, and returning all personal items. RN 1 stated that the actual discharge planning such as identifying placement, arranging transportation and coordinating post-discharge services, is the responsibility of the social services department. RN 1 stated when he (RN 1) later learned that Resident 1 and Resident 2 had been discharged to an unlicensed board and care facility, he (RN 1) became very concerned about their safety. During an interview on 8/27/2025 at 11:08 a.m., with MD 1, MD 1 stated that she (MD 1) was sitting at the nursing station when the FM approached her (MD 1) and informed her (MD 1) that a board and care placement was available for Resident 1 and Resident 2. MD 1 stated that she (MD 1) asked the FM whether the discharge would be safe, and the FM responded Yes. MD 1 further stated that the FM then wrote down the name and address of the board and care on a piece of paper and that the information given to her (MD 1) by FM was that of BC 1. MD 1 stated that RN 1 was also present at the nursing station at the time and witnessed the interaction. MD 1 stated that it is not typical for the FM to be involved in discharge planning and placement of her (MD 1) residents, as this is usually handled by the Social Services Department. MD 1 stated that she (MD 1) assumed the FM was coordinating with the SSAT and trusted that BC 1 had been properly vetted (investigated or examined thoroughly) based on the FM's assurance that BC 1 was a safe discharge option. MD 1 stated that she (MD 1) is not aware of Resident 1's current status, as another physician was assigned to the resident following discharge. During a concurrent interview and record review on 8/28/2025 at 3:25 p.m., with the MRD, Resident 1's entire medical record from 4/1/2025 to 8/8/2025 was reviewed. The MRD stated that she (MRD) reviewed Resident 1's entire medical record from 4/1/2025 to 8/8/2025 and was unable to locate any documentation from Resident 1's physician (MD 1) indicating the basis of discharge for Resident 1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/11/2025 with diagnosis that included encephalopathy, fracture of the right humerus (upper arm bone), and atrial fibrillation (irregular heartbeat that increases the risk of stroke and heart disease). During a review of Resident 2's H&P, dated 7/13/2025, the H&P indicated Resident 2 has the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS further indicated Resident 2 needed maximal assistance from staff for toileting hygiene, upper and lower body dressing, putting on/taking off footwear and moderate assistance with personal hygiene. The MDS also indicated Resident 2 occasionally exhibited urine incontinence and frequently exhibited bowel incontinence. During a review of Resident 2's Physician's Order, dated 8/7/2025, timed at 5:31 p.m., the Physician's Order indicated to discharge Resident 2 home to BC 1 tomorrow (8/8/2025), per the resident's request. During a review of Resident 2's Notice of Proposed Transfer and Discharge, dated 8/8/2025, the Notice of Proposed Transfer and Discharge indicated that Resident 2 was discharged to BC 1 on 8/8/2025. The Notice of Proposed Transfer and Discharge also indicated that the reason for discharge was that Resident 2's health had improved sufficiently, and Resident 2 no longer required the services provided by the facility. During a review of Resident 2's Discharge Summary 056133 Page 7 of 8 056133 08/29/2025 West Hills Health and Rehabilitation Center 7940 Topanga Canyon Blvd. Canoga Park, CA 91304

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Report, dated 8/8/2025, the Discharge Summary Report indicated Resident 2 was discharged to BC 1 on 8/8/2025 at 2:20 p.m. During a review of Resident 2's Active Discharge Planning Notes (from GACH 2), dated 8/19/2025, the Active Discharge Planning Notes indicated that Resident 2 was transferred to GACH 2 from an unlicensed board and care facility and was treated for hyperkalemia. Laboratory test results dated 8/19/2025 at 7:13 p.m. indicated an elevated potassium level of 5.8 mEq/L. The notes indicated that Resident 2 appeared weak and required transfer to a skilled nursing facility for continued care. The notes indicated that Resident 2 cannot return to the board and care facility due to its unlicensed status.During an interview on 8/26/2025 at 12:45 p.m. with Resident 2, Resident 2 stated he (Resident 2) was not involved in any discharge planning. Resident 2 stated that no one asked him (Resident 2) where he (Resident 2) wanted to go after his (Resident 2) stay at the facility and that he (Resident 2) was unaware he (Resident 2) had any choice or input in the matter. Resident 2 stated that he (Resident 2) trusted the facility to make decisions on his (Resident 2) behalf. Resident 2 further stated that he (Resident 2) does not clearly remember being discharged to BC 1 but does recall being taken to GACH 2, although he (Resident 2) does not remember the reason for the transfer. Resident 2 stated that staff (unable to recall who) at GACH 2 informed him he (Resident 2) could not return to the place he came from (BC 1) because it was unlicensed. Resident 2 stated that following his (Resident 2) stay at GACH 2, he (Resident 2) was transferred back to SNF 1.During a concurrent interview and record review on 8/26/2025 at 1:32 p.m., with the SSAT, Resident 2's Social Services Notes from 7/11/2025 to 8/8/2025 were reviewed. The SSAT stated that there were no discharge planning notes found, and no documented evidence found in Resident 2's medical record indicating who arranged Resident 2's transfer to BC 1. The SSAT stated that there should have been documentation in Resident 2's medical records reflecting coordination between the facility and BC 1. The SSAT further stated that she (SSAT) was not aware of Resident 2's discharge to BC 1 until after Resident 2 was discharged , when she (SSAT) was asked to make a follow-up call on 8/12/2025. The SSAT stated she (SSAT) made several follow-up calls to Resident 2 on 8/12/2025 and kept getting a busy signal so she (SSAT) was unable to speak to Resident 2. The SSAT stated she (SSAT) was not informed of the discharge plan and was not involved in Resident 2's discharge process at any point. The SSAT further stated that she (SSAT) ) does not know who coordinated Resident 2's discharge with BC 1 and w[TRUNCATED] 056133 Page 8 of 8